Health System Change and Reform in Canada

Monitoring Health System Change/Health ReformsPAHO/WHO Seminar, Belize, 30 May 2006

Gregory P. MarchildonCanada Research Chair in Public Policy and Economic History

Graduate School of Public Policy, University of Regina

G.P. MarchildonGraduate School of Public Policy

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Outline of Presentation

• Organization

• Fiscal Resources

• Physical and Human Resources

• Health Services

• Health Reforms: Phase I

• Health Reforms: Phase II

• Performance Indicators

Public, Mixed and Private Systems of Health Care

Funding Administration Delivery

Public Canada Health Act services (hospital and physician services plus) and public health services

Public Taxation Universal, single-payer provincial systems. Private self-regulating professions subject to provincial legislative framework

Private professional, private not-for-profit, private-for-profit and public arm’s-length facilities and organizations

Mixed goods and service, including most prescription drugs, home care and institutional care services

Public taxation, private insurance and out-of-pocket payments

Public services that are generally welfare-based and targeted, private services regulated in the public interest by governments

Private professional, private not-for-profit and for-profit, and public arm’s-length facilities and organizations

Private goods and services including most dental and vision care as well as over-the-counter drugs and alternative medicines

Private insurance and out-of-pocket payments including full payments, co-payments and deductibles

Private ownership and control; private professions, some self regulating with public regulation of food, drugs and natural health products

Private providers and private for-profit facilities and organizations

Organization of the Public Health Care System

Canadian Constitution

Provincial and Territorial Governments Federal Government

Canadian Institutes

for Health Research

Statistics Canada

Minister of HealthRegional Health

Authorities

Ministries of Health

Mental Health and Public Health

Home Care and

Long-Term Care

Single Payer

Hospital, primary care and physician Services

Canada Health Act,

1984

Health Canada

Public Health Agency of Canada

Patent Medicine

Prices Review Board

Provincial and Territorial Prescription Drug Subsidy Programs

Federal-Provincial-Territorial Advisory

Committees and Councils

Transfer payments

Canada Health

Infoway

Canadian Coordinating

Office of Health

Technology

Health Council of

Canada

Canadian Institute for

Health Information

Canadian Blood

Services

G.P. MarchildonGraduate School of Public Policy

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Revenue Sources for all Health Expenditures, 2003

Overview of Canadian Health System: Expenditure Perspective

Private Sector30.4%

Private Health Insurance

Other

Dental and vision care, drugs, complementary and alternative

medicine, and some long term care and home care

Out-of-Pocket Expenditures

Commercial Insurance Firms

Not-for-Profit Insurance Firms

Public Sector69.6%

Provincial GovernmentSector63.3%

Hospitals

Long-term Care

Other Public Sector6.3%

Federal Direct4.2%

Municipal(Public Health)

0.7%

Community Care

Social Security Funds1.4%

Quebec Drug Insurance Fund

Physician Remuneration

Provincial Drug Plans

Home Care

Regional Health Authorities

Total Health Expenditures 2005$142 Billion

Worker’s Compensation

Trends in Health Expenditures, 1976-2005

Five-Year Averages 1976-1980

1981-1985

1986-1990

1991-1995

1996-2000

2001-2005

Total health expenditure (THE) as % of GDP 7.0 8.0 8.5 9.6 9.0 10.0

Canada Health Act (CHA) services as % of THE 58.1 56.7 55.4 51.7 46.2 43.3

CHA services as % of GDP 4.1 4.5 4.7 5.0 4.2 4.3

Non-CHA services as % of THE 41.9 43.3 44.6 48.3 53.8 56.7

Non-CHA services as % of GDP 2.9 3.5 4.7 4.6 4.9 5.7 Mean annual growth rate in THE 12.8 12.4 8.9 4.0 5.8 7.7 Mean annual growth rate in CHA services 11.6 12.2 8.2 1.8 3.8 6.8 Mean annual growth rate in non-CHA services 14.6 12.7 9.8 6.3 7.5 8.4 Mean annual growth rate in GDP 12.6 9.1 7.0 3.6 5.8 4.8 Mean real annual growth rate in THE 3.3 4.2 4.0 1.6 4.0 5.2 Mean real annual growth rate in CHA services 2.2 4.0 3.3 -0.5 2.1 4.3 Mean real annual growth rate in non-CHA services 4.9 4.5 4.8 3.9 5.7 5.9 Mean real annual growth rate in GDP 3.6 3.1 2.3 2.0 4.3 2.5

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CHA$51.5B 61.3%Provincial/Territorial

$89.8B 63.3%

Federal Direct$5.9B4.2%

Other Public Sector $3.0B 2.2%

Private Sector $43.2B 30.4%

CHA$55.7B39.2%

Canada Health Act Expenditures as a Share of Total Health Care, 2005

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1998 1999 2000 2001 2002 2003 20041998-2004

Provincial/Territorial Rx plans except Quebec 10.7 13.3 16.6 14.6 12.2 10.4 11.7 12.8

Quebec Rx Plan 26.8 21.0 25.9 14.3 18.6 22.4 12.5 20.2

NIHB Rx Plan 7.6 3.7 9.6 9.6 9.5 12.9 11.3 9.2

Private Rx Plans 15.6 20.1 -12.4 32.5 11.5 9.6 9.8 12.4

Hospital Expenditures 5.1 4.2 8.3 5.4 6.8 7.1 5.7 6.1

Physician Expenditures 4.8 4.3 6.2 7.7 7.7 6.4 4.8 6.0

Gross Domestic Product 3.7 7.4 9.6 2.9 4.2 5.4 6.1 5.6

Annual Growth Rates of Prescription Drug (Rx) Plans, other Components of Health Expenditures and Canadian GDP, 1998-2004 (Current Prices)

Total Health care expenditures as a share of GDP in Canada and selected countries, 1960 to 2002

0

2

4

6

8

10

12

14

161

96

0

19

70

19

80

19

85

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

% o

f G

DP

AUST CAN FR SWE UK US

Public Health Care Expenditures as a share of GDP in Canada and selected countries, 1960 to 2002

0

1

2

3

4

5

6

7

8

91

96

0

19

70

19

80

19

85

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

% o

f G

DP

AUST CAN FR SWE UK US

Comparison of Selected Imaging Technologies (per million)

20

01

20

01

20

0219

99

20

0220

01

20

00

20

00

20

01

20

02

19

99

20

02

20

01

19

95

0

5

10

15

20

25A

US

T

CA

N

FR

SW

E

UK

US

OE

CD

Mea

n

MRIs CT scanners

Health Care Personnel in Canada (per 1,000 people), 1991-2003

1991 1995 2000 2003

Family Physicians 1.07 1.03 1.00 0.97

Specialist Physicians 1.05 1.08 1.10 0.91

Registered Nurses n/a 7.93 7.58 7.60

Dentists 0.52 0.54 0.56 0.58

Pharmacists 0.71 0.76 0.80 0.87

Physiotherapists 0.39 0.43 0.47 0.49

Optometrists 0.10 0.10 0.11 0.12

Medical Laboratory Technician 0.70 0.65 0.58 0.60

Medical Radiation Technologists 0.50 0.49 0.47 0.48

Occupational Therapists 0.19 0.24 0.29 0.33

Psychologists 0.33 0.38 0.41 0.45

Chiropractors 0.14 0.15 0.18 0.21

Midwives 0.00 0.00 0.01 0.01

Province % Decline

British Columbia

Alberta

Saskatchewan

Manitoba

Ontario

Quebec

New Brunswick

Nova Scotia

Prince Edward Island

Newfoundland and Labrador

-14.6

-2.8

-19.2

-12.2

-12.3

-14.2

-12.1

-19.1

-12.8

-21.3

Canada -12.9

Decline in the number of recorded hospital admissions for Canada and provinces, 1995-2001

Note: The % decline is calculated on age-standardized hospitalization rates for all conditions, per 100 000 population

Comparison of Active Physicians (per 1,000), 1980 to latest year

1

1.5

2

2.5

3

3.5

19

80

19

85

19

90

19

95

20

00

20

01

20

02

AUST CAN FR SWE UK USA

4

5

6

7

8

9

10

11

121

98

0

19

85

19

90

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

AUST CAN FR SWE UK US

Comparison of Active Nurses (per 1,000), 1980 to latest year

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Health Services I

• Public health

• Primary care

• Secondary/inpatient care

• Rehabilitation/intermediate care

• Long-term care, home care and other community care

• Prescription drugs …

G.P. MarchildonGraduate School of Public Policy

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Health Services II

• Palliative care

• Mental health care

• Dental health care

• CAM products and services

• Maternal and child health care

• Services for informal caregivers

• Aboriginal Canadians

G.P. MarchildonGraduate School of Public Policy

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Health Reforms I, 1988-1996

• Public fiscal restraint due to– Rapidly growing health care costs– High public debt

• Cost-cutting and disinvestment and patient dissatisfaction but also…

• Profound Organizational and Managerial change: integration and coordination

• The regionalization revolution

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Health Reforms II, 1997 to now

• Public reinvestment and growing costs• Rival hypotheses as to cause and effect

– Public-private debate: delivery and financing

• Major Consensus– Primary Care Reform– Managing system: regionalization and integration

• Post-Chaoulli– Move from delivery to heart of medicare– Single-payer administration and finance

Performance Indicators

Life Expectancy and Mortality Indicators, 1970-2001

1970 1980 1990 2000 2001 Life expectancy (Females at birth – Years) n/a 78.9 80.8 82 82.2 Life expectancy (Males at birth – Years) n/a 71.7 74.4 76.7 77.1 Life expectancy (Total population at birth – Years) n/a 75.3 77.6 79.4 79.7 Infant mortality (Deaths /1,000 live births) 18.8 10.4 6.8 5.3 5.2 Maternal mortality (Deaths/100,000 live births) 20.0 8 2.5 3.4 7.8 Potential Years of Lost Life (Per 100,000, aged 0-74) n/a 6,250 4,716 3,571 n/a All Malignant neoplasms (Deaths /100000 pop.)

Lung cancer (Deaths /100,000 pop.). Prostate Cancer (Deaths /100,000 pop.). Breast Cancer (Deaths /100,000 pop.). Colorectal Cancer (Deaths /100,000 pop.).

183.4 30.5 24.0 30.2 30.9

185.8 42.9 25.7 29.7 25.0

191.7 51.1 30.1 31.3 21.1

175.7 46.9 24.6 24.5 17.1

178.7 n/a n/a n/a n/a

Digestive Diseases (Deaths /100,000 pop.) 31.8 32.5 24.7 21.3 n/a All circulatory disease (Deaths /100,000 pop.)

Acute Myocardial Infarction (Deaths /100,000 pop.) Cerebrovascular disease (Deaths /100,000 pop.) Ischaemic heart diseases (Deaths /100,000 pop.)

488.4 n/a 100.8 309.4

379.1 139.9 70.2 231.8

260.7 86.1 47.6 154.2

191.5 52.1 37.8 108.5

n/a n/a n/a n/a

Respiratory disease (Deaths /100,000 pop.) Pneumonia and Influenza (Deaths /100,000 pop.)

64.7 36.1

52.3 22.3

55.9 22.0

44.3 n/a

n/a n/a

Infectious and Parasitic disease deaths (Deaths /100,000 pop.)

HIV (Deaths /100,000 pop.)

7.0 n/a

3.6 n/a

7.8 3.2

8.3 1.4

n/a n/a

Mental and behavioural disorders (Deaths /100,000 pop.) 2.7 6.1 9.6 13.6 n/a

External causes (Deaths /100,000 pop.) 70.9 65.5 46.9 38.2 n/a

Factors Influencing Health Status, 1981-2002

1981 1986 1991 1996 1997 1998 1999 2000 2001 2002

Total calories intake (per capita)

2337 2411 2356 2585 n/a 2715 2725 2732 2757 2788

Alcohol consumption (litres per capita, 15+)

97.8 92.2 83.4 77.8 78.5 79.8 80.8 81.2 80.6 81.1

Daily smokers (% of pop.) 32.8 28.3 25.9 24.5 23.8 23.7 20.9 19.8 18.0 17.8

Obese population (% of total pop. BMI > 30kg/m2)

n/a n/a 12.2 12.2 14.6 n/a 14.5 n/a 14.9 14.9

Immunizations

Measles (% of children >2 years of age)

n/a n/a n/a 97.0 96.0 96.2 n/a n/a n/a n/a

Diphtheria, Tetanus and Pertussis (% of children >2 years of age)

n/a n/a n/a 87.1 86.8 84.2 n/a n/a n/a n/a

Table 2.3A: Overall Provincial Performance Based on Conference Board of Canada’s Weighted Count of Health Indicators

Province and Ranking Weighted Count

Number of Indicators Reported

Weighted Count per Reported Indicator

1. British Columbia 153 117 1.31

2. Alberta 133 119 1.12

3. Saskatchewan 125 111 1.13

4. Ontario 122 113 1.08

5. Quebec 121 99 1.22

6. New Brunswick 113 113 1.00

7. Prince Edward Island 104 104 1.00

8. Newfoundland and Labrador 98 103 0.95

9. Nova Scotia 98 114 0.86

10. Manitoba 92 114 0.81

Source: Derived from Conference Board of Canada (2006), tables 1-2, p. 4.

Malignant Neoplasms

(2000)

Cerebro-vascular Diseases

(2000)

Respiratory

System Diseases

(2000)

Ischaemic Heart

Diseases (2000)

SWEDEN 1 (2) 5 (11) 1 (4) 4 (16)

CANADA 4 (15) 1 (2) 3 (10) 3 (12)

AUSTRALIA 2 (8) 4 (5) 4 (12) 2 (11)

FRANCE 5 (18) 2 (3) 2 (8) 1 (3)

UK 6 (20) 6 (18) 6 (25) 6 (22)

USA 3 (14) 3 (4) 5 (22) 5 (21)

Comparative Disease Indicator Rankings (OECD rankings in brackets), 2000

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2001 - % Excellent or Good

2003 - % Excellent or Good

BC

AB

SK

MB

ON

QC

NB

NS

PEI

NL

YK

NT

NU

CANADA

84.0

83.6

85.6

80.3

84.5

85.0

82.8

85.3

89.6

88.9

81.7

80.5

70.8

84.4

82.8

85.7

88.4

85.6

87.1

89.0

86.9

87.3

88.6

86.1

85.3

79.1

77.1

86.8

Satisfaction with Health Care and/or Health System