Health Policy

HSCI 130: Foundations in Health Sciences

By Robert Hogg
 Land Acknowledgement
Let me begin by acknowledging that I am an uninvited settler
on the unceded traditional territories of the Coast Salish
speaking peoples. Specifically, the sháshíshálh-speaking
peoples of shíshálh Nation, the Sḵwx̱wú7mesh sníchim-
speaking people of Sḵwx̱wú7mesh Nation, and the
hən̓q̓əmin̓əm̓-speaking Tsleil-Waututh and xʷməθkʷəy̓əm, and
kʷikʷəƛ̓əm Nations.
BC First Nations
26 Cultural Groups
34 Languages
203 Bands (or First Nations)
1 Health authority (FNHA)
3 Provincial First Nations
Organizations
• BC Assembly of
• First Nations
• First Nations Summit
• Union of BC Indian Chiefs
For more information on efforts to
revitalize BC First Nations
languages, visit: www.fpcc.ca
CONTENT WARNING: RACISM & VIOLENCE
• The settler colonial state of Canada is responsible for a genocide
of Indigenous peoples, and ongoing efforts to assimilate,
silence, and control the narrative of Indigenous peoples across
diverse nations and regions.
• This lecture contains information, including text, some photos,
and a video discussing real-life examples of racism and violence
perpetrated against Indigenous individuals by healthcare staff.
• If you are connected to or impacted by these systems of
oppression in Canada, and feel that you would rather not
participate in discussions about these incidents in class, please
do not hesitate to take time for yourself away from this lecture,
and/or reach out to me for support and alternative ways to
engage with this material.
 IN THIS PLACE, WE BELIEVE
BLACK LIVES MATTER.
LOVE IS LOVE
INDIGENOUS RIGHTS ARE HUMAN RIGHTS
WATER IS LIFE
PEOPLE COME BEFORE PROFITS
YOU ARE ENOUGH
KINDNESS WINS ALL
OUR COLLECTIVE BEAUTY IS IN OUR DIVERSITY
Lecture Overview
1. Canadian Healthcare System
2. History
3. Canadian System
4. Indigenous Health
5. International Comparison
6. Wait Times
7. Health Policy
8. Commissions and Inquiries
Readings
1. Stall NM, Jones A, Brown KA, Rochon PA, Costa
AP. For-profit long-term care homes and the
risk of COVID-19 outbreaks and resident deaths
CMAJ, 2020 192 (33): E946-E955.
Myth-buster Exercise
• On one slide:
• State the policy myth-buster in
one sentence, and
• Provide up to 3 bullet points
supporting your myth-buster in
sentence form.
• You get 0.5 marks for the
myth-buster and 0.5 marks for
each correct bullet.
Upload your slide and title slide
on Canvas.
Tutorial
• Objective: To develop a plan to engage the public in evidence-informed policymaking.
• Submit three PowerPoint slides (see Rubric)
• Review the research article and comment on how Senior’s care in Canada has impacted the
spread of COVID19 in senior care homes.

Required materials:
• Stall NM, Jones A, Brown KA, Rochon PA, Costa AP. For-profit long-term care homes and the
risk of COVID-19 outbreaks and resident deaths CMAJ, 2020 192 (33): E946-E955.
Sources
• Kalysha Closson and Chenoa Cassidy-Matthews
• Other sources: Wikipedia, Laurie Goldsmith,
Pauline Vaillancourt Rosenau and other sources
listed throughout the presentation.
Canadian Healthcare System
Canada’s Healthcare System
• Publicly financed and privately delivered
• 14 interlocking systems: healthcare service delivery is the purview of the individual
provinces & territories, and the federal government provides fiscal support
• Health support for Indigenous people is seen as the federal government’s responsibility, as
outlined in the Indian Act (1876)
• The Canada Health Act (1984) lays out the rules and a national “minimum standard”
for the provinces to follow
• The defining feature of Canada’s Healthcare System: it is universal and publicly
financed health insurance for medically necessary hospital and physician services
• No user fees or extra-billing
 Federal Government:
Roles and Responsibilities
• Legislation
Canada Health Act
• Funding
Canada Health and Social Transfer
• Program delivery
Direct provider of health care services for certain groups
(e.g., First Nations and Inuit, veterans and members of the
military, and Royal Canadian Mounted Police)
• Population and public health programs Health protection
and regulatory activities Health research
Source: Stolberg, J Am Coll Radiology, 2009
 Provincial and Territorial Governments:
Roles and Responsibilities
• Management and delivery of health care services Insured
health care services (e.g., medically necessary hospital and
physician services) Supplementary programs (e.g.,
prescription drugs, home care)
• Funding health care services
• Health research
• Public health and health promotion

Source: Stolberg, J Am Coll Radiology, 2009

Provincial & Territorial Responsibilities
• Health services delivery and management
• Managing prescription care (e.g. PharmaCare in BC) and
some areas of public health (e.g. BC CDC)
• Hospital care planning, financing, and evaluating, physician
hiring and management, and allied health care services
Canadian Healthcare System

Martin et al., Lancet 2018

History
 Jurisdictional History
• 1867 British North America Act
• Division of health responsibilities:
• Provinces:
• financing, management and delivery of health services

• Federal:
• Health protection, disease prevention, health promotion
• Health services delivery to veterans, native Canadians living on
reserves, military personnel, inmates of federal penitentiaries,
and the RCMP
 Timeline 1940-50s
• 1947: Led by Premier Tommy Douglas, the Saskatchewan Hospital Services Plan is
introduced as the first universal hospital insurance program in North America

• 1957: Led by Prime Minister Louis St. Laurent, the Hospital Insurance and
Diagnostic Services Act establishes 50:50 cost sharing with provincial hospital
insurance plans that meet the criteria of comprehensiveness, universality,
accessibility, and portability (user fees are discouraged despite no explicit
prohibition)

• 1958: Implementation of the Hospital Insurance and Diagnostic Services Act, with
five provinces participating

• 1959: Premier Tommy Douglas announces his plan for universal publicly funded
medical insurance coverage (Medicare) in Saskatchewan
 Timeline 1960s
• 1960: Organized medicine launches a large-scale campaign against Medicare

• 1961: All ten provinces now participating in the Hospital Insurance and Diagnostic
Services Act

• July 1, 1962: The Saskatchewan Medical Care Insurance Act takes effect,
establishing universal publicly funded medical insurance for Saskatchewan
residents

• July 1–23, 1962: Saskatchewan doctors’ strike, led by the Keep our Doctors
committee

• 1964: Led by Justice Emmett Hall, the Royal Commission on Health Services
recommends comprehensive universal health coverage for all Canadians
 Timeline 1960s (Continued)
• 1965: Led by Prime Minister Lester Pearson, federal Liberals announce support for
50:50 cost sharing with provincial health plans that meet the criteria of
comprehensiveness, portability, universality, and public administration

• Dec 8, 1966: The Medical Care Insurance Act is passed in Parliament, legislating
federal support of provincial Medicare plans that meet the criteria of
comprehensiveness, portability, universality, and public administration

• July 1, 1968: The Medical Care Insurance Act comes into effect
 Timeline 1970s
• 1971/72: All provinces now have established comprehensive medical insurance
plans that meet the federal criteria for funding eligibility and in 1972 expanded
plans to include physician services.

• 1977: Led by Prime Minister Pierre Elliott Trudeau, federal Liberals introduce
Established Programs Financing, which provides block funding transfers to
provinces and lessens federal involvement in health-care provision

• 1979: Led by Justice Emmett Hall, the Health Services Review raises concerns about
the increase in user fees and extra billing by physicians

• 1979: The Indian Health Policy is adopted, formalizing the federal government’s
responsibility for health-care provision for Indigenous Canadians as directed by
constitutional and statutory provisions, treaties, and customary practice
 Timeline 1980s
• 1982: Prime Minister Pierre Elliott Trudeau and Queen Elizabeth II sign the
Constitution Act, establishing Canadian sovereignty through patriation; previously
established Constitutional convention remained unchanged, including provincial
jurisdiction over health service delivery and financing, and

• 1984: Under Minister of National Health and Welfare Monique Bégin, the Canada
Health Act is passed unanimously by Parliament, explicitly banning extra billing and
establishing criteria for transfer payment eligibility (with penalties for violations):
public administration, comprehensiveness, universality, portability, and accessibility

• 1987: All provinces and territories in compliance with the Canada Health Act – e.g.
ban all extra billing.
Timeline 1990s onward
• 1990s: Reductions in federal transfer payments.

• 1995: Canada Health and Social Transfer introduced

• 2000: Federal government agreed to provide new funds

• 2000: Canadian Institutes of Health Research established

• 2003: Federal government again increased funding to provinces

• 2004: First Minister’s introduce a 10-year plan, mainly directed at wait times and
Pharmacare

• 2004: Creation of the Public Health Agency of Canada

 Pillars of the Canadian Health Act
• Accessibility: The provincial and territorial plans must provide all insured persons reasonable
access to medically necessary hospital and physician services without financial or other
barriers.
• Comprehensiveness: The provincial and territorial plans must insure all medically necessary
services provided by hospitals, medical practitioners and dentists working within a hospital
setting.
• Portability: The provincial and territorial plans must cover all insured persons when they
move to another province or territory within Canada and when they travel abroad. The
provinces and territories have some limits on coverage for services provided outside Canada
and may require prior approval for non-emergency services delivered outside their
jurisdiction.
• Public Administration: The provincial and territorial plans must be administered and
operated on a non-profit basis by a public authority accountable to the provincial or
territorial government.
• Universality: The provincial and territorial plans must entitle all insured persons to health
insurance coverage on uniform terms and conditions.
 Values
• Community welfare
• Social contract
• Healthcare system is the most popular social program in
Canada
 Canada Health Act Coverage
• Covers “medically necessary” physician and hospital services
• Dependent on federal government transfers
• Additional principles recommended:
• Accountability
• Sustainability
Services Outside of the Canadian Health Act
• Dental care
• Home care
• Long-term care
• Prescription drugs
• Physiotherapy
Canadian System
Living and Working in the Canadian System

• With few exceptions, Canadians NEVER worry about incurring

health care expenses
• Nor do Canadians have to submit claims to insurers
• Providers have ONE payer to submit claims to: the provincial
government
• Canadian system is largely funded by general tax revenue: 25-50%
federal
Related to Government Intervention and Regulation

• Canadians think they have“good government”

• Americans distrust their government
• Canadians are comfortable with price controls in the health
sector
• Price controls in the health sector yield lower costs
• Unlike other economic sectors unfettered market
competition does not lower costs
 Payments in Canada
• Fee for service for most primary care and specialists - bills sent
to the province
• Extra-billing of patient is NOT permitted
• No individual bills are prepared for patients
• Hospitals (largely private nonprofit) are paid on global budget
system with funds sent by the province; some regional health
authorities obtain population-based funding (west) (HiT 2004)
• Payment for pharmaceuticals varies by province and formularies
are set up at the provincial level
Source: http://www.health.gov.bc.ca/msp/infoprac/physbilling/payschedule/index.html
 How Doctors Bill in Canada
• Billing is straightforward but lots of variation across provinces as
each takes care of its on billing
• Doctor must be registered as a practitioner in the province
• Doctor must have a billing number – and not automatic
• Doctor must be eligible and qualified to bill for the specific code
indicated: ex. neurologist won’t be paid for doing an appendectomy.
• The amount billed must be for the amount allowed by the fee
schedule (Medical Services Plan)
How Doctors Bill in Canada (continued)
• Bills are submitted electronically on forms online through the web or
via a direct connection to the MSP office – daily or weekly- and 98%
reimbursed
• The provincial payer organization sends payment twice monthly
directly to the MD and pay interest on reimbursements that are
delayed more than 30 days.
• Ease of billing is a big plus in Canada and doctors who have billed in
both US and Canada are in agreement on this: “One insurer, one fee
schedule, rarely any question of eligibility and no incentive to
withhold payment – its heaven compared to the US”.
 Health Human Resources in Canada
• Over 1,000,000 people in Canada worked directly in health occupations; this represented 6%
of the total Canadian workforce in 2006.
• Health care providers may be regulated (through professional colleges or other bodies) or
non-regulated, unionized or non-unionized, employed, self-employed or volunteer.
• Most doctors work in independent or group practices and are not employed by the
government.
• Nurses are primarily employed in acute care institutions (hospitals); however, they also
provide community health care, including home care and public health services.
• Dentists mostly work in independent practices; in general, their services are not covered
under the publicly funded health care system, except where in-hospital dental surgery is
required.
• Allied health professionals include: dental hygienists; laboratory and medical technicians;
optometrists; pharmacists; physio and occupational therapists; psychologists; speech
language pathologists and audiologists.
Indigenous Health
 Indigenous Health
• 1876 Indian Act
• 1979 Indian Health Policy
• 1985 Indian Act
• Jordan’s Principle
• Non-insured health benefits (NIHB)
 1876 Indian Act
Preceded by separate pieces of colonial legislation including
the Gradual Civilization Act of 1857 that were consolidated as
the Indian Act in 1876
States that Indigenous services are a federal responsibility
The original Indian Act is widely acknowledged to have been
an instrument of assimilation and several policy documents
and pieces of legislation have been adopted since then to
help guide or clarify roles and responsibilities.
Potlatch Law & Section 141: In 1884, one of the most infamous examples of oppression
through the Indian act is the ban on potlatches and other ceremonies such as the sun dance
 1979 Indian Health Policy
• A brief, two-page document that specifies the relationship between the federal
government and Indigenous peoples with respect to health care,
• Outlines the complex, interlocking roles of nature of the “Federal, Provincial or
Municipal Governments, Indian bands, or the private sector” in managing,
financing, and delivering health services to Indigenous Peoples
• The policy outlines the role of the federal government as “public health activities on
reserves, health promotion, and the detection and mitigation of hazards to health in
the environment” while the provinces play a role “in the diagnosis and treatment of
acute and chronic disease and in the rehabilitation of the sick.”
• Indigenous communities “have a significant role to play in health promotion, and in
the adaptation of health services delivery to the specific needs of their community.”
 1985 Indian Act
Bill C-31 and Gender Discrimination
• Amended in 1985 to address gender discrimination found in Section 12 that called
for the removal of a woman’s Indian status if she married a non-Indian man
• After repeated losses in the Supreme Court of Canada for many women who came
forward to fight this discrimination, Sandra Lovelace brought her case to the UN
and won, as it is in direct violation the International Covenant on Civil and Political
rights that protects a minority’s right to belong to their cultural group
• Bill C-31 was still seen as controversial, as it allowed women who regained status to
pass on their status to only one generation; leaving grandchildren unable to obtain
status
• In 2011 Bill C-3 was passed to finally remove all gender discrimination from the
Indian Act
 Health Services for Indigenous
Peoples Today: NIHB
The Non-Insured Health Benefits (NIHB) program provides eligible First Nations* and
Inuit clients with coverage for a range of health benefits that are not covered through
other: social programs, private insurance plans, provincial or territorial health
insurance
NIHB covers:
• Vision care
• Dental care**
• Mental health counselling
• Medical supplies and equipment
• Prescription and over-the-counter medications
• Medical transportation to access medically required health services that are not
available on reserve or in the community of residence
 Jordan’s Principle
• Established in response to the death of five-
year-old Jordan River Anderson, a child
from Norway House Cree Nation who
suffered from Carey Fineman Ziter
syndrome, a rare muscular disorder that
required years of medical treatment in a
Winnipeg hospital.
• After spending the first two years of his life
in a hospital, doctors cleared Jordan to live
with his family.
• The federal and provincial governments
would not let him go home, because they
could not resolve who was financially
responsible for the necessary home care.
• At the age of five, Jordan died in the
hospital; he never had the opportunity to
live in a family home.
• Jordan’s Principle ensures that First
Nations children can access all public
services when they need them. Services
need to be culturally-based and take into
full account the historical disadvantage
linked to colonization that many First
Nations children live with. The government
of first contact pays for the service and
resolves jurisdictional/payment disputes
later.
• Please view:
https://www.youtube.com/watch?v=j-
xAloD75dQ
Sources: First Nations Child & Family Caring Society
Government of Canada: https://www.sac-
isc.gc.ca/eng/1568396042341/1568396159824
FN Caring Society: https://fncaringsociety.com/jordans-principle
 Indigenous Harmful Encounters
in Healthcare
Systemic racism Experiences

• Direct effects of stress arising from • Concerns are discounted

interactions that are perceived to be • Assumptions are made about
discriminatory behavior.
• The denial of access to resources such as • Blamed or belittled
healthcare that fits with peoples’ needs,
• Cultural health practices are
• The internalization of stigma and sidelined
discrimination,
• Rights are undermined
• The vigilance that is required in anticipation
of negative treatment, which leads to stress
and often tense social interactions

Brenda Gunn Faculty of Law, University of Manitoba

Human Experimentation
and Residential Schools
• Indigenous children were deliberately starved in the 1940s and
’50s by government researchers in the name of science.
• Milk rations were halved for years at residential schools across
the country.
• Essential vitamins were kept from people who needed them.
• Dental services were withheld because gum health was a
measuring tool for scientists and dental care would distort
research.
• For over a decade, Indigenous children and adults were
unknowingly subjected to nutritional experiments by Canadian
government bureaucrats.

Mosby, Histoire sociale/Social History XLVI, 91 (Mai/May 2013), 615-642

Impact of the Residential
School Diets
• The typical residential school diet was characterized by
insufficient caloric intake, minimal protein and fat, severely
limited access to fresh fruit and vegetables, and frequent
bouts of food-borne infection.
• Studies of children exposed to the 20th-century famines
report greater prevalence of obesity, overweight, diabetes
and hypertension; greater incidence of heart attack and
stroke; elevated fasting plasma glucose and unfavourable
lipid profiles among famine survivors compared with non-
stressed controls
• Childhood malnutrition in residential schools as one of the
most important factors influencing Indigenous health

Mosby, CMAJ 2017

 How Systemic Racism Affects
Population and Patient Health
• Colonial policies: Mandatory residential schools, the outlawing of Indigenous gatherings and ceremonies, forced
community dislocations, and discriminatory child welfare legislation have had lasting and intergenerational effects on
mental health, family relationships, and Indigenous language and culture. The summary report of the Truth and
Reconciliation Commission provides important narratives, a detailing of historical and ongoing effects of colonial
policies, and recommendations for action.
• Limited healthy food choices: Dispossession of traditional lands has interfered with traditional economies and access
to traditional foods; urban, rural, and remote Indigenous peoples often have inadequate access to affordable healthy
and nutritious foods.
• Inadequate living conditions: Indigenous peoples living in cities and rural and remote communities are faced with
inadequate housing and living conditions. For example, the peoples of Inuit Nunangat experience overcrowding and
poor respiratory health from low-quality housing stock, leading to elevated rates of TB infection compared with the
general Canadian population.
• Substandard health care: In addition to the differential access to acute cardiac imaging and intervention discussed
above, studies describe high levels of perceived interpersonal racism toward Indigenous patients from health care
providers across health care settings. Experiences of racism, including unfair treatment as a result of racism, have
been reported in multiple Indigenous survey studies, across geographic settings, with prevalence rates ranging from
39 per cent to 78 per cent. In one Canadian study, this was so severe that Indigenous patients strategized on how to
manage racism before seeking care in the emergency room.
International Comparison
Growth of Healthcare Spending in Canada since 1975

Source: Canadian Institutes of Health Information

How does Canada’s
Health Spending
Compare?
• Although Canada is above the
OECD average in terms of per-
person spending on health care, the
public-sector share of total health
expenditure is below the OECD
average.

Source: Canadian Institutes of Health Information

Wide Variations in Health Lifestyles

Reference: Krueger, Bhaloo, & Rosenau; “Health Lifestyles in the U.S. and Canada: Are We Really So Different?
“Forthcoming Social Science Quarterly, December 2009
 Americans and Canadians on Access
and Health Outcomes
• Very poor Americans are in poorer health than their
Canadian counterparts
• Wealthy Americans and Canadians – equally healthy
• Little difference between insured Americans and Canadians
as a whole -- on access to health care and health status
• Americans without health insurance are – different, with low
access to health care and more “unmet health care needs”

• Alexis Pozen, David M. Cutler (2010) Medical Spending Differences in the United States and Canada: The Role of Prices, Procedures, and Administrative Expenses. Inquiry: Summer 2010,
Vol. 47, No. 2, pp. 124-134.
 Why do the US and Canada Differ as
to Health System Preference?
• Culture – maybe but USA and Canada are converging; media, proximity, culture diffusion, geographic
mobility and immigration
• History – Yes
• More distrust of government in US
• More emphasis on individual liberty
• Form of government – Yes
• Presidential system in the USA
• Roots in the constitution
• Designed to require incremental policy rather than comprehensive policy
• Parliamentary system in Canada
• Good at implementing comprehensive change quickly and efficiently
• Responsible party model
• Important role for party leadership
Wait Times
 Wait Times
• Historically this has been the Achilles heel of the Canadian
system
• Result of budget cuts 1990’s
• Today the situation is much improved
• But the U.S. also has a “waiting times” problem, but for
different reasons
• In the US patients wait because of cost…..
• In Canada patients because of scarcity
 Wait Times for Elective Care
• Urgent medical and surgical care is generally timely and of
high quality in Canada
• However, the timeliness of elective care, such as hip and
knee replacements, non-urgent advanced imaging, and
outpatient specialty visits, is problematic.
• The proportion of Canadians waiting more than 2 months
for a specialist referral is 30%, which is far greater than any
European care.
 Benchmark for Treatment and Wait Time

Percent of cases getting care by bench mark

Hip Fracture Repair

182 days

Knee Replacement
182 days

Hip Replacement
48 hours

0 10 20 30 40 50 60 70 80 90 100

Source: Canadian Institute of Health Information

 Amenable/Premature Mortality
• Amenable mortality: “defined as deaths from a collection of
diseases, such as diabetes and appendicitis, that are
potentially preventable given effective and timely health
care”1
• Canada’s reasonable performance on composite quality
metrics such as amenable mortality suggests that these
wait times for elective care do not necessarily translate to
worse health outcomes.
• However, for the Canadian public, long wait times for
elective care are a lightning rod issue and threaten to
undermine support for Medicare.
1. Ramkissoon, F. E. (2013). Commentary on “In Amenable Mortality –
Deaths Avoidable Through Health Care – Progress in the US Lags That
of Three European Countries”. Annals of Medicine and Surgery, 2(1), 5-
7. doi:https://doi.org/10.1016/S2049-0801(13)70018-9
 Premature Morality 2017
Age-standardized rate per 100,000

Ischemic
heart Lung Neonatal Road Colorectal Alzheimer's
disease cancer Self-harm disorders injuries Stroke cancer disease COPD
Canada 947.1 634.2 513.9 460.0 336.9 307.5 273.4 254.3 245.1
Australia 800.9 439.9 515.0 325.7 295.5 309.3 278.0 280.7 268.5
Belgium 801.8 701.9 595.9 274.9 320.6 389.4 256.9 296.7 321.8
Finland 1,213.9 395.1 593.3 155.3 199.6 440.0 201.2 476.0 157.2
Germany 1,181.8 627.5 400.4 324.3 219.4 393.2 284.2 299.7 281.4
Ireland 991.2 534.1 395.9 247.1 160.5 344.9 282.3 298.9 298.1
Singapore 877.2 353.8 300.2 78.2 138.5 332.3 239.4 219.4 107.2
South Korea 419.0 413.4 768.6 284.3 322.8 534.0 225.0 372.1 135.3
Sweden 946.1 367.4 484.2 209.0 146.6 360.1 261.9 288.6 201.6
Switzerland 648.0 428.8 373.8 327.7 142.0 222.8 186.4 291.7 154.0
United States 1,476.0 697.5 587.0 547.8 600.3 454.2 297.1 349.9 461.7

Orange: significantly higher than the mean Source: http://www.healthdata.org

Blue: significantly lower than the mean
Health Policy
Catalysts for Health Policy
 Access to Healthcare
• Having access:
• Are services available?
• Is there an adequate supply of services
• Gaining access/Utilization:
• Financial affordability
• Physical/organizational accessibility
• Social and cultural acceptability
• Measuring "access" may actually measure just one or a few domains
of access (like availability, affordability and/or acceptability), but
rarely all of them
 Cost of Healthcare
• Measuring cost of care is easier than measuring the VALUE
of that care
• Included: Fixed costs (facilities and utilities), variable costs
(labour and benefits), payment for services, payments for
goods, losses from non-payment
• Excluded: Opportunity costs, costs of educating health
professionals, expenditures on the determinants of health
 Quality of Healthcare (six aims)
• Safety: ensure that the medical care intended to benefit patients is not causing
harm.
• Effectiveness: Medical treatments must be based on scientific knowledge, and must
produce beneficial, measurable results.
• Patient-centered: Care must be tailored to individual patient preferences, needs and
values. Patients should have authority over their own medical care, and their input
must guide clinical decision- making.
• Timeliness: Patients requiring medical attention should have access to timely
healthcare and follow-up care to avoid potentially harmful delays in treatment.
• Efficiency: Quality health care avoids wasting finances, time, equipment, and
energy. Efficiency maximizes the impact of global health organizations.
• Equitability: The quality of medical care must be consistent across all patients,
irrespective of gender, ethnicity, socioeconomic status, and other personal
characteristics.

Source: The Institute of Medicine

 Characteristics of Indigenous
Primary Healthcare Service Delivery Models
• Systematic review identify the
characteristics of Indigenous primary
health care service delivery models.
• Found that culture was the most
prominent characteristic.
• Other characteristics include:
accessible health services, community
participation, continuous quality
improvement, culturally appropriate
and skilled workforce, flexible approach
to care, holistic health care, and self-
determination and empowerment.

Harfield et al.,Globalization and Health, 2018

 Health in All Policies
• An approach that
systematically considers the
health and social implications
of policies contemplated by
all sectors of government
• Aiming for synergistic
benefits and to minimize
social and health-related
harms
• These types of policy are a
critical policy lever, because
many of the drivers for health
outcomes are beyond the
reach of the health sector
Tonelli et al., CMAJ 2020
Commissions and Inquiries
 National Commissions and Inquiries
on Healthcare in Canada, 1960-70s
• 1961–64: Royal Commission on Health Services(Hall Commission): Led by Justice
Emmett Hall, the Commission recommended comprehensive health coverage for all
Canadians and development of national policy in health services, health personnel,
and health-care financing.
• 1973–74: A New Perspective on the Health of Canadians (Lalonde Report): Led by
Marc Lalonde, Canadian Minister of National Health and Welfare, this paper
introduced the public health imperative and called for the prevention of illness and
promotion of good health. It called for the expansion of the health-care system
beyond disease-based medical care.
• 1979–80: Health Services Review: Led by Justice Emmett Hall, this review reported
on the progress made since the 1964 commission and sought to determine whether
provinces were meeting the criteria of the Medical Care Insurance Act. This inquiry
identified widespread extra billing and user fees and served as a catalyst for the
Canada Health Act.
 National Commissions and Inquiries
on Healthcare in Canada, 1990s
• 1991–96: Royal Commission on Aboriginal Peoples: The Commission investigated
the evolution of the relationship between Aboriginal and non-Aboriginal people and
governments in Canada. Major recommendations included the training of 10 000
health professionals over a 10-year period.
• 1993–97: Commission of Inquiry on the Blood System in Canada (Krever Inquiry):
Led by Justice Horace Krever, the Commission investigated the use of contaminated
blood products that infected 2000 transfusion recipients with HIV and 30 000 with
hepatitis C between 1980 and 1990. This Commission led to the creation of Canadian
Blood Services in 1998.
• 1994–97: National Forum on Health: Commissioned by Prime Minister Jean
Chrétien, this group of experts from across Canada focused on broad determinants
of health and the need for enhanced emphasis on evidence-based care.
 National Commissions and Inquiries
on Healthcare in Canada, 2000s
• 1999–2002: Standing Senate Committee on Social Affairs, Science and Technology
Study on the State of the Health Care System in Canada (Kirby Committee). Led by
Senator Michael Kirby, this committee conducted a comprehensive review of
Canadian health care. Recommendations included a call for enhanced federal
oversight to ensure effective care and efficient resource use, and highlighted poor
health human resource planning as a cause of geographical inequities.
• 2001–02: Commission on the Future of Health Care in Canada (Romanow
Commission): Led by former Saskatchewan Premier Roy Romanow, the
Commission called for a renewed commitment to the values of equity, fairness, and
solidarity. The report was the catalyst for the 2003 “Accords” and the establishment
of the Health Council of Canada (defunded in 2014) to monitor progress on key
objectives.
 National Commissions and Inquiries on
Healthcare in Canada, 2000s (cont’d)
• 2003: National Advisory Committee on Severe Acute Respiratory Syndrome (SARS)
and Public Health: Led by David Naylor, this committee was established to review
the circumstances of the 2003 SARS outbreak. The report identified significant
issues with public health in Canada and led to the creation of the Public Health
Agency of Canada.
• 2008–15: Truth and Reconciliation Commission of Canada Undertaken as part of
holistic and comprehensive response to the systemic abuse suffered by Indigenous
Canadians under the Indian Residential School system, the commission identified
calls to action to advance reconciliation. Although not specifically focused on health
care, the report highlighted substantial gaps in health care for Indigenous people
and outlined the substantial impact of the trauma on mental and physical health.
• 2015: Advisory Panel on Healthcare Innovation: Led by David Naylor, the panel’s
Unleashing Innovation report highlighted the need for enhanced patient
engagement, workforce modernisation, technological transformation, and improved
scale-up of existing innovations.
 Romanow: Building on Values
There are two competing visions
and guiding values about health
care. Each would take our nation
down a fundamentally different
path.

One view is based on the premise

that health care is a commodity –
that medical needs ebb and flow
with markets, and they determine
who gets care, when, and how.
 Romanow: The Other Value
The other vision backed by evidence and
public opinion, strongly believes that
health care is a “public good.”

It believes that democratically elected

governments, as representatives of the
public, not corporate bottom lines,
should define common needs, provide
equitable services, and a reasonable
allocation of resources.

Fairness, equity, compassion, and

solidarity: these are the values that were
adopted and nurtured throughout
Canada’s history of shared destiny.
 Romanow: “Building on Values”(3)
These values gain their expression in
our core belief that everyone should
have access to our health care
system on the same terms and
conditions, and that this access is
ultimately a right of Canadian
citizenship.

These values are manifested through

our view that Medicare is a truly
national program – a nation-defining
and nation-building enterprise.
 Future
• Tension between private and public forces
• Pushing for Phase 2 of Medicare:
• Focus on “preventive medicine”
• Including homecare, long-term care, community care,
pharmacare, social determinants of health
• Continued fight for healthcare equity in Canada
must include dismantling the Indian Act
Next Week: Population Dynamics