The incidence of illness and trends in
diseases greatly differs between men and women and within sub-populations such
as Aboriginal peoples, children and youth, as well as between different
socio-economic groups. The
economic burden of disease is significant and must be seen to include not only
direct health care costs, but also lost productivity and lower quality of
There are concerns that new diseases and
increasingly prevalent illnesses may have a significant impact on the current
and future costs of health care. However,
many of the causes of disease, disability and early death are preventable.
It has been suggested that increasing efforts in the area of health
promotion and disease prevention, with a particular focus on Canadians with
low incomes and low levels of education, must remain key areas in public
policy if we are to improve overall health status and contain health care
and renal disease
bronchitis and pneumonia
of early infancy
duodenitis, enteritis and colitis
diseases (heart disease and stroke)
obstructive pulmonary diseases
and degenerative diseases of the central nervous system
of the arteries, arterioles and capillaries
Nota: Disease categories not
identical over time. Rates in
1996-97 are age-standardized. Source:
Susan Crompton, “100 Years of Health,” Canadian Social Trends,
Statistics Canada, Catalogue 11-008, No. 59, Winter 2000, p. 13.
Public health programs, combined with the
large-scale introduction of vaccines and antibiotics, have led to a major
shift in the pattern of diseases. Today,
although cardiovascular disease remains the leading cause of death among
Canadians, its impact on mortality has declined dramatically over the past 70
years, probably reflecting changes in lifestyles (reduced levels of smoking,
lower-fat diets, more exercise) and improvements in treatment (new drugs and
improved medical/surgical techniques). In
contrast, cancer has become the second cause of death in Canada, compared to
fifth in 1921.
Dr. Paul Gully, Acting Director General at
the Centre for Infectious Disease Prevention and Control (Health Canada), told
the Committee that although some infectious diseases have been controlled or
virtually cured, many infectious diseases persist. Indeed, he stated that: “since 1980, the death rate from
infectious diseases in Canada has increased.”
Infectious diseases are a significant economic burden, costing more
than $6 billion annually in 1998.
Dr. Gully pointed to seven infectious disease trends that threaten
Many infectious diseases, such as AIDS and
hepatitis C, persist;
There are new and emerging disease threats,
including mad cow disease and E. coli, as well as the West Nile Virus
Global travel and migration can introduce new
diseases into the population;
Environmental changes, such as global
warming, deforestation, and tainted water, may cause infections, such as Lyme
Behavioural changes, particularly high-risk
sexual practices and drug use, can spread HIV and other diseases;
Resistance to immunization could cause a
resurgence in polio and measles, for example; and
Anti-microbial resistance may reduce the
effectiveness of traditional curative measures.
According to the National Population Health
Survey, in 1998-99, more than half of all Canadians, or 16 million, reported
having a chronic condition. The
most prevalent conditions were allergies, asthma, arthritis, back problems,
and high blood pressure.
In a written brief to the Committee, Dr. David MacLean, Department
Head, Community and Epidemiology, Dalhousie University, noted:
Chronic non-communicable diseases are
the major health burden today in developed countries like Canada.
They are by far the most important cause of all mortality, premature
mortality, morbidity, and years of potential life years lost in Canada.
They are the leading causes of disability, loss of productivity, and
deterioration in the quality of life.
Cardiovascular disease is the major cause
of death in Canada, accounting for 37% of all deaths. Mortality from
cardiovascular disease has been declining in Canada since 1970 among both men
and women, although more slowly in women. Cancer in its many forms is the
second-leading cause of death and the leading cause of potential years of life
lost before age 70 (over one-third of all potential years of life lost).
Cancer is primarily a disease of older Canadians, with 70% of new cancer cases
and 82% of deaths due to cancer occurring among those who are at least 60
years old. Cancer death rates
have declined slowly for men since 1990, while they have remained relatively
stable among women over the same period.
However, lung cancer rates for women are now four times higher than
they were in 1971.
identified some of the factors that are affecting the incidence of chronic
disease. More precisely, poor
diet, lack of exercise, smoking, stress, excessive alcohol intake, and obesity
were all identified as chronic disease risk factors.
Dr. MacLean suggested that most chronic diseases - such as cancers,
heart disease, diabetes, and respiratory disease - are “entirely
preventable” and, moreover, that the social and biological determinants of
chronic diseases “can be manipulated.”
In his view, however, there is a tendency to focus on curing chronic
diseases, rather than preventing them. He
said that the most common chronic disease strategy “has been to deal with
the issue largely as a clinical problem with significant health care resources
invested in the development of specialized services utilising sophisticated
diagnostic and treatment technologies.”
Dr. MacLean noted that there is a limited political will to expend
resources on prevention because “the outcomes from preventative work are
long term. There are no short
payoffs. For some parts of the
political process, that is not an attractive issue.”
In 1995-96, there were 217,000 hospital
admissions due to injury. By far,
the highest rates of hospital admissions due to injuries were among Canadians
over the age of 65. The rate was
lower among people under the age of 45. Falls
remain an important cause of injury among seniors and children under 12.
Among children, the next most important cause of injury-related
admission to hospital in 1996 was poisoning.
For adolescents and adults under the age of 65, the second most
important cause was motor vehicle crashes.
The vast majority of injuries are accidental (about 66%).
In her brief, Dr. Christina Mills, Director General, Centre for Chronic
Disease Prevention and Control (CCDPC) at Health Canada, indicated that each
year, $9.5 billion in direct costs are the result of injuries, in addition to
$4.7 billion in compensation costs. Most
of these injuries are preventable.
The National Population Health Survey of
1994/95 found that approximately 29% of Canadians had a high level of stress;
6% of Canadians felt depressed; 16% of Canadians reported that their lives
were adversely affected by stress; and 9% had some cognitive impairment such
as difficulties with thinking and remembering.
Work prepared for the Federal/ Provincial/ Territorial Advisory Network
on Mental Health estimated that about 3% of Canadians suffer from severe and
chronic mental disorders that can cause serious functional limitations and
social and economic impairment such as manic depression and schizophrenia.
This translates into approximately one in every 35 Canadians over 15
years of age.
Mental stresses and disorders leading to
mental illness can strike at different periods of life. Autism, behavioural problems and attention deficit disorder
most commonly affect children. Adolescence
is typical for the onset of eating disorders and schizophrenia.
Adulthood is a time when depression may manifest more obviously.
Seniors years are marred by Alzheimer’s and other types of dementia
although depression is also being identified more often in the elderly.
According to data provided to the
Committee, the total cost of illness was estimated at $156.4 billion in 1998.
Direct costs (such as hospital care, physician services and health
research) amounted to $81.8 billion, while indirect costs (such as lost
productivity) accounted for $74.6 billion.
The diagnostic categories with the highest total costs were
cardiovascular diseases, musculoskeletal diseases, cancer, injuries,
respiratory diseases, diseases of the nervous system, and mental disorders.
The economic burden of mental health
problems were estimated at approximately $14 billion in 1998. Mental illnesses and disorders were the seventh highest among
all diseases in terms of the overall cost of illness. It is estimated that mental illness is the second-leading
cause of hospital use among those aged 20 to 44, a period of life normally
associated with high productivity.
Disease issues are complex.
This complexity is attributable to the fact that poor or good health is
dependent on a variety of factors such as biology and genetic endowment, as
well as the physical environment and socio-economic conditions in which an
individual lives. More
importantly, it is the interaction among these various factors that can have a
significant impact on one’s state of health.
For example, Dr. MacLean noted: “Illness generally results from the
interaction between an individual’s genetic make up and broad environmental
This was echoed by Dr. Mills who stated that: “many major conditions
share common risk factors” and, moreover, risk factors often “cluster
together” in individuals.
According to many experts, the most
powerful influence on health is socio-economic status. Whether we look at how
people rate their own health, premature mortality, psychological well-being or
the incidence of chronic disease, socio-economic status remains strongly
related to health status. Differences
in health status are readily evident in a comparison of the highest and lowest
income groups. Canadians with low
incomes and low levels of education (which are often related) are more likely
to have poor health status, no matter which measure of health is used, and
people’s health improves on virtually all measures and in all of the factors
that influence health as levels of income and education increase. Canadians with low incomes are also more likely to die
earlier than other Canadians, no matter which cause of death is considered.
But an active gradient in health status from low to middle and upper levels of
income can also be observed in virtually all measures of both mortality and
morbidity. In other words, high-income Canadians are more likely to be healthy
than middle-income Canadians, who are in turn healthier than low-income
Canadians. Indeed, it is estimated that if the same death rates as for the
highest income earners applied to all Canadians, over one-fifth of all
potential years of life lost before age 65 could be prevented.
thread woven through the witnesses’ presentations was the need to invest
more in prevention and promotion strategies.
They pointed out that currently, there is a tendency to focus on curing
diseases, rather than on preventing them.
In their view, clinical treatment has been the most common strategy and
there has been only a limited political will to expend resources on health
promotion and disease prevention, because outcomes from preventive work are
generally visible only over the longer term, and are therefore less attractive
stressed that with appropriate disease prevention and health promotion
strategies, many chronic and infectious diseases, and most injuries, can be
prevented. According to Dr.
Mills, investing in promotion and prevention is the only way to reverse
disease trends and reduce the burden of illness:
Our only chance to slow or reverse the
rate of increase [in the economic burden of disease] is to invest in effective
upstream prevention. It is quite
well recognized now that failure to prepare for an increased burden due to the
aging population is a threat to the sustainability of our health care system,
but it is not widely recognized that our failure to invest upstream is an
equally great, and perhaps even greater, threat to sustainability.
Witnesses stressed that it is necessary to
encourage people to make smart choices with regard to their own health.
They suggested that, to date, strategies that attempted to prescribe
“good behaviour” have not been entirely successful, and noted that part of
the challenge lies in creating an environment that allows people themselves to
make the right choices.
Prevention and promotion efforts have to be
tailored and flexible. There is no “one size fits all” strategy.
For example, sexually transmitted disease trends change as sexual
practices change and therefore will always require new prevention and
promotion strategies. In this
regard it is important to ensure that the marketing of health information be
current. Witnesses pointed to the
Canada Food Guide as an example of a good initiative, but one that has not
been marketed effectively or updated and adapted over time.
must also recognize the link between healthy communities and healthy citizens.
For example, people may be less inclined to bike or jog if the streets
are unsafe. Successful
community-based programs combine an understanding of the community, with the
participation of the public, and the cooperation of community organizations.
Approaches that address several risk factors and that can produce multiple
benefits include support for families at risk, comprehensive school health
promotion programs, and comprehensive work health and safety programs.
Furthermore, because disease and injury are
not uniformly distributed across populations, strategies must also look at the
linkages between health status and demographic and environmental factors, such
as age, race, region of residence, and gender. Strategies must therefore
address disease and injury trends among specific demographic groups, such as
youth and Aboriginal peoples. For
example, suicides and motor vehicle accidents predominantly affect young men
and Aboriginal youth. Adults over
age 65 are most affected by falls, and accidents are the leading cause of
death in children. Strategies
must be tailored to the situations of each affected group, and need to be
targeted to the groups that will derive the most benefit from prevention.
Many witnesses pointed to the need for
intergovernmental cooperation, in order to implement prevention and promotion
programs. They noted that all
three levels of government should be involved, given the complexity and
multiple dimensions of health issues. Dr.
MacLean recommended that:
(…) the federal government use its
time-honoured way of influencing provinces, which is the 50-cent dollars.
The federal government could start by making a policy priority of
trying to increase the infrastructure for prevention because they have to work
with the provinces on these issues.
…We have never had a cost-shared process
for public health.
One difficulty that arises with regard to
the elaboration of strategies for health promotion and disease prevention is
that many diseases usually have several risk factors associated with them.
Comprehensive prevention and promotion strategies must therefore
address the linkages between risk factors, as well as between health status
and socio-economic, demographic, and environmental factors.
Approaches that address several risk factors and which can produce
multiple benefits include support for families at risk, comprehensive school
health promotion programs, and comprehensive work health and safety programs.
Approaches like these can be part of a broader population health
Witnesses explained that several key issues
with regard to population health strategies largely revolve around the
difficulties associated with how to translate research evidence into actual
policy that can be implemented. In
their view, there can be little doubt that population health strategies would
result in improved health outcomes, but there remain significant practical
obstacles to moving beyond the expression of pious good wishes to the design
of concrete programs that are sustainable over the long haul.
In the first place, the multiplicity of
factors that influence health outcomes means that it is exceedingly difficult
to associate cause and effect, especially because the effects are often only
felt many years after exposure to the cause. The Committee was told that this
time lag also means that the timeframe for judging the impact of policy in
this area is a long term one. Because political horizons are often of a
shorter-term nature, this can constitute a serious disincentive for the
elaboration and implementation of population health strategies.
as noted earlier, a massive infrastructure that is already in place to deal
with the treatment of illness, and this creates many entrenched interests
within the system. Witnesses
explained that it is not necessarily that people who treat illness have
anything against promoting health — the contrary is no doubt the norm.
Rather, it is simply that massive resources must be deployed simply to
sustain the existing health care infrastructure, making it difficult to find
sufficient time, energy and capital to devote to the preventive, or wellness,
side of the system.
Moreover, the Committee heard that because
of the diversity of the factors that influence health outcomes, it is very
difficult to coordinate government activity in the area of population health.
Given that the health care system itself is only responsible for a
relatively small percentage of the actual determinants of health, the
responsibility for population health cannot reside exclusively with the
various ministries of health. Yet
the structure of most individual governments does not easily lend itself to
inter-ministerial regulation of complex problems, and this difficulty is
compounded several times over when the various levels of government, along
with the many non-governmental players, are taken into account, as they must
For example, the evidence concerning the
existence of gradients of health that correlate with socio-economic levels is
quite conclusive. The implication
of this fact is that the promotion of population health requires a strong
focus on the reduction of poverty. But
there are clearly a great number of government policies that have an impact on
the levels of poverty in the country and it would be impossible to ask a
ministry of health to take charge of all the policy tools that are involved,
if for no other reason than this would be rightly seen as a form of ‘health
imperialism’ by other ministries. It is also somewhat perverse, as one
witness pointed out, to argue for the reduction of poverty exclusively on the
health terrain. Any such
initiative would have to come about as a result of the overall social policy
orientation of government, something that is considerably broader than health
Overall, the evidence suggests that
population health strategies in general should be carefully thought through so
that they take into account the realities facing specific communities.
This implies that rigidly-designed programs applied in a uniform and
highly centralized fashion are unlikely to succeed.
Some combination of coordination and decentralized implementation
therefore would seem to be required.
Although there are many difficulties
associated with the development of an effective population health approach,
the witnesses contended that it is important for the federal government to
continue to try to set an example by exploring innovative ways to turn good
theory into sound practice that will contribute to improving health outcomes
Many witnesses told the Committee that
greater research is needed, particularly in certain areas. Often, money is
spent without sufficient epidemiological research to guide where it is
invested. For example, billions
of dollars have been spent on breast cancer screening programs, but there has
been minimal research on the physiology and biology of the disease, or on the
intersection of risk factors that contribute to its development.
Dr. MacLean also told the Committee that
more research on prevention strategies is needed.
He pointed to the budgetary increases for the Canadian Institutes of
Health Research (CIHR), but wondered whether or not those new resources would
be directed at health promotion and disease prevention research.
Dr. Mills noted that CIHR’s expanded mandate offers an “opportunity
to support additional research required to determine what is most effective to
create lasting behaviour change.”
In terms of chronic disease research,
witnesses told the Committee that the problem, essentially, is not a lack of
data or research, but a lack of knowledge on how to use that information in
the implementation of preventive strategies.
In this respect, research is needed to determine how best to share
health information with people and, in particular, how best to target that
information to those in lower socio-economic groups or those with poor
In terms of infectious disease research,
Dr. Gully noted that although resources are being directed to research
initiatives, such as the CIHR and the Health Canada laboratory in Winnipeg,
“it is always difficult to make a bid for contingency funds for new
[infectious disease] threats.”
He pointed to the difficulty of balancing resources for immediate
threats with those for other, less immediate, issues.
With respect to mental illness, witnesses
stressed the need to invest more in applied research. In their view, research into mental illness and mental health
is vastly under-funded in relation to the economic burden of mental disease
and disorder. It was suggested
that the federal government should take the lead in promoting a comprehensive
research agenda on the mental health issue.
Witnesses indicated that we need to spend
more on the infrastructure for disseminating the evidence generated by health
research. According to Dr. Gully,
federal funding in this area would allow data to be collected from, and shared
among, all of the provinces and territories.
He pointed to the Internet as a tool for such an undertaking.
This idea was echoed by Dr. MacLean, who told the Committee about the
Health Promotion web site developed in Nova Scotia, which provides
health-related information to users.
Although the witnesses addressed a wide
range of issues, the primary emphasis was on the need to increase disease
prevention and health promotion programs.
Witnesses noted that the federal government could play an important
role in preventing disease and promoting healthy lifestyles.
Moreover, they suggested that appropriate, comprehensive, and targeted
disease prevention and health promotion programs would have a significant
effect on both the health of Canadians and Canada’s health care system.
Such programs would improve quality of life, increase productivity,
decrease unintentional disability and premature death, and reduce the economic
burden of disease.
Canada is one of the healthiest countries
in the world, with high life expectancy, low infant mortality rates, and a
good quality of life. These
successes, however, should not conceal the challenges that persist.
Chronic diseases - such as cancer, heart disease, and respiratory
problems - are the leading cause of death in Canada.
Diseases that had, at one time, virtually disappeared, such as
tuberculosis, are re-emerging, and increased international mobility has
accelerated the spread of other diseases.
Moreover, in 1997, accidents killed more than 13,000 Canadians.
Finally, the prevalence of disease varies among different demographic
groups and populations, striking, in particular, Aboriginal peoples, and the
A diversity of factors influences health
outcomes. Population health
strategies are broadly based policies that take all these determinants of
health into account with the aim of improving the health of an entire
population. The main objective of
population health is to ward off potential health problems before they require
treatment within the health care system.
These strategies can greatly contain the demand for health services and
reduce the economic burden of disease.
The Committee concurs with witnesses that
the federal government has a definite role in health promotion and disease
prevention. Similarly, the
federal government has been recognized as a leader worldwide in developing the
concept of population health. In
our view, the federal government should, once again, show leadership in
implementing a population health strategy for all Canadians.
This is a feasible task, given its current role in many areas that
affect health, such as the environment, economic policy, workplace safety,
There are notable
disparities between the health of Canada’s Aboriginal population and the
health of the general Canadian population.
The Aboriginal population experiences poorer health, lower life
expectancies, higher infant mortality rates and higher rates of some chronic
illness. There are also
significant socio-economic disparities between Aboriginal people and the
general population – unemployment rates are higher and education and average
income levels are lower.
This chapter provides a brief demographic,
socio-economic and health profile of Canada’s Aboriginal population.
It also highlights federal programs directed to Aboriginal health and
discusses the Aboriginal health policy of the federal government.
Aboriginal people constitute approximately
3% of Canada’s total population. The
Constitution Act, 1982 recognizes
three groups of Aboriginal peoples: Indians, Inuit, and Métis.
The Indian population includes both status and non-status Indians.
The Indian Act sets out the
legal definitions that apply to status Indians (First Nations) in Canada, that
is, Indians who are registered under the Indian
Act. Non-Status Indians are
those who are not registered under the Act.
The Inuit population of Canada lives primarily in communities in the
Northwest Territories, Nunavut, Nunavik and Labrador. About 6% of Inuit live in southern Canada.
Inuit are not specifically covered by the Indian
Act but receive certain benefits from the federal government.
Métis people are of mixed Indian and European ancestry. The Métis are not covered by the Indian Act and do not receive Métis-specific benefits from the
As Graph 5.1 shows, Canada’s total
Aboriginal population was estimated at 1,398,400 in 2000 and comprised: 28.5%
of Status Indians living on reserve, 30.6% of Non-status Indians, 20.8% of
Status Indians off reserve, 15.6% of Métis, and 4.5% of Inuit.
Canada’s Aboriginal population is
diverse. There are over 600 First Nations communities, comprising over 50
nations or cultural groups and more than 50 languages.
Approximately 63% of First Nations communities have fewer than 500
residents — 5% have more than 2,000. Although
the Inuit communities share the same language, Inuktitut, they have different
dialects from one region to another. Most Inuit communities have fewer than 1,000 persons.
The Métis have developed their own distinct language, known as Michif,
from a mixture of French, English, Cree and Ojibway.
The Métis population is mainly concentrated in Manitoba, Saskatchewan
and Alberta; about 10% of them live in Métis settlement lands.
Canada’s Aboriginal population is
becoming increasingly urbanized. The
urban Aboriginal population experienced rapid growth between 1981 and 1991,
increasing by 55 percent (compared to an 11 percent increase in urban
non-Aboriginal residents). Although
its future rate of growth is expected to be slower, the urban Aboriginal
population is still anticipated to grow by 43 percent in the next 25 years,
from 320,000 in 1991 to 457,000 in 2016.
In 1996, about one-fifth of the Aboriginal population lived in seven of
the country’s 25 largest census metropolitan areas – Winnipeg, Edmonton,
Vancouver, Saskatoon, Toronto, Calgary and Regina.
Overall, the Aboriginal population is
growing at twice the rate of the Canadian population and is younger on average
than Canada’s general population. In
1996, the average age of the Aboriginal population was 25.5 years, 10 years
younger than the average age of the general population. Children under age 15 comprised 34% of all Aboriginal people,
compared to 21% of Canada’s total population.
Young people in the 15-24 age range constituted a greater portion of
the Aboriginal population (18%) compared to the general population at 14%.
Seniors currently make up a relatively small proportion of the
Aboriginal population in Canada. In 1996, just 4% of people who reported they were North
American Indian, Métis, or Inuit were aged 65 and over, compared with 11% of
the general population.
There are significant socio-economic
disparities between Aboriginal peoples and the general Canadian population.
Aboriginal peoples are less likely to be in the labour force, and
unemployment rates are higher than those of the general population.
In 1997-98, the unemployment rate on reserves was almost triple the
national rate, and reliance on social assistance was four times the Canadian
rate. The Royal Commission on
Aboriginal Peoples (1996) reported that the unemployment rate for the urban
Aboriginal population was two and a half times greater than that of their
non-Aboriginal counterparts. In
1995, the average employment income of the Aboriginal population was $17,382
compared to the national average of $26,474.
Average annual income from all sources for Aboriginal people in urban
areas trailed 33 percent behind that of non-Aboriginal residents.
According to the recent report, Toward
a Healthy Future: Second Report on the Health of Canadians, in 1994 at
least 44 percent of the Aboriginal population and 60 percent of Aboriginal
children under six years of age lived below Statistics Canada’s low income
cut off measure.
The incidence of poverty among the urban Aboriginal population is high.
The 1991 census found that more than 60 percent of Aboriginal
households in Winnipeg, Regina and Saskatoon were below the low-income cut-off
line. For single-parent
households headed by women, the percentage was even higher.
Overall, levels of educational attainment
among the Aboriginal population are lower than those of the Canadian
population as a whole. In 1996,
54 percent of the Aboriginal population aged 15 years and over did not have a
high school diploma. The comparable figure for the non-Aboriginal population
was 16 percent. Differences
between 1981 and 1996 data show improvement in educational attainment – the
proportion of the Aboriginal population with less than a high school education
dropped from 59 percent to 45 percent, a greater proportion of the Aboriginal
population aged 20 to 29 had obtained a college degree or diploma (23 percent
in 1996, 19 percent in 1981) and the proportion of Aboriginal university
graduates rose by 1 percent (from 3 percent to 4 percent), but are still below
comparable measures for the general Canadian population.
Second Diagnostic on the Health of First Nations and Inuit People in Canada
noted that one’s “physical environment is an important factor in the
exposure to risks such as infectious organisms, chemical and biological
contaminants, stress levels, and injury.”
The report made the following points about the physical environment of many
Aboriginal people appear to be the largest
population sub-group that is the most at risk of becoming homeless in Canada;
Crowded housing conditions are much more
prevalent among the Aboriginal population than among the general Canadian
Significant numbers of Aboriginal people
(43%) live in inadequate housing;
Mold growth is a recently identified issue in
aboriginal housing but the full extent and impact on health is not yet known;
First Nations and Inuit people are more at
risk of exposure to environmental contaminants because of their traditional
diet of fish and marine mammals;
Access to clean, safe drinking water and
adequate sewage disposal is an issue for a number of Aboriginal communities.
There are significant differences in health
status between the Aboriginal population and the Canadian population.
Toward a Healthy Future: Second
Report on the Health of Canadians noted that the Aboriginal population
experiences poorer health than the general Canadian population, as evidenced
by lower life expectancies, higher infant mortality rates and higher rates of
some chronic illness. Many other reports made similar observations:
people suffer from chronic diseases (hypertension, arthritis, diabetes and
heart disease) more so than the general population. Diabetes is one of the
leading causes of illness and disability among First Nations.
Current evidence indicates that diabetes is more than three times as
prevalent in Aboriginal communities as in the general population. The
following table of chronic disease rates taken from A
Second Diagnostic on the Health of
First Nations and Inuit People in Canada, illustrates the depth of the
chronic disease problem among the Aboriginal population.
ADJUSTED PREVALENCE (%)
NATIONS AND INUIT
Source: Table taken from A
Second Diagnostic on the Health of First Nations and Inuit People in Canada,
November 1999, p. 17.
First Nations men and women on reserves have
approximately three times the rate of heart problems and hypertension compared
to the general Canadian population. (First Nations and Inuit Regional Health Survey, National Report 1999).
Between 1991 and 1996, age-standardized
tuberculosis rates were almost seven times higher among First Nations persons
living on reserves than the rate for the general Canadian population. The
current incidence of TB among First Nations living on reserves is 18 times
higher than the rate for the Canadian-born non-Aboriginal population (A
Second Diagnostic on the Health of
First Nations and Inuit People in Canada).
Despite major improvements since the 1970s,
infant mortality rates for First Nations communities continue to be double the
rate for Canada as a whole (Toward a
Healthy Future: Second Report on the Health of Canadians).
The suicide rate among the Aboriginal
population for all age groups is about three times higher than the rate for
the population of Canada as a whole
(A Second Diagnostic on
the Health of First Nations and Inuit People in Canada).
Among Aboriginal youth, the suicide rate is five to six times higher
than the suicide rate of the general Canadian youth population.
Data taken from Evaluation of
Models of Health Care Delivery in Inuit Regions indicate that the suicide
rate for Canada’s Inuit regions is approximately 6 times higher than the
rate for the general Canadian population.
Alcohol, substance and solvent abuse is
common in a number of First Nations and Inuit communities.
Fetal Alcohol Syndrome/Fetal Alcohol Effects
is much higher in some Aboriginal Communities than in other parts of Canada (A
Second Diagnostic on the Health of
First Nations and Inuit People in Canada).
The rate of deaths due to injuries and
poisonings is 6.5 times higher for First Nations and Inuit than for the total
Canadian population (A Second Diagnostic
on the Health of First Nations and Inuit
People in Canada).
A 1999 study reported that the annual number
of Aboriginal AIDS cases has increased significantly.
In 1996-97, cases had risen to 10% of the total AIDS cases (up from 2%
Smoking is more prevalent in the Aboriginal
population. The First Nations and
Inuit Regional Health Survey indicates that 62% of adult First Nations peoples
living on reserve and in Labrador Inuit communities are smokers and over 70%
of all respondents to the survey aged 20-29 were smokers.
Obesity is a major health problem among the
Approximately 75% of Aboriginal women are
victims of family violence and up to 40% of children in some Northern
communities have been physically abused by a family member (A
Second Diagnostic on the Health of First Nations and Inuit Peopole in Canada)
Overall, life expectancy rates for Aboriginal
peoples are lower by some
6 years than comparable statistics for the general population.
Many Aboriginal people have reduced access to
health care services because of the remote geographical location and small
size of several Aboriginal communities. Seventy-seven
percent of communities have fewer than 1,000 people and many (44 percent) are
found in isolated, semi-isolated or remote-isolated areas of Canada.
Health care is delivered to Canada’s
Aboriginal people through a complex array of federal, provincial and
Aboriginal-run programs and services. In
addition, the framework for the delivery of a number of federal programs is
changing as Aboriginal communities, governments and organizations take control
over the delivery of health-related programs.
Who delivers what to whom depends on a
number of factors such as status under the Indian
Act, place of residence (on or off-reserve), the location of one’s
community (non-isolated or remote), and whether Health Canada has signed an
agreement to transfer the delivery of certain health services to an Aboriginal
community or organization.
In his testimony, Ian Potter, Assistant
Deputy Minister, First Nations and Inuit Health Branch at Health Canada, told
the Committee that Status Indians (First Nations) under the Indian Act are a federal responsibility. The provision of hospital and physician services, however, is
a provincial or territorial responsibility.
First Nations who reside on reserves are entitled to the general health
services provided by the provinces and territories such as hospitals,
physician services, and other insured services covered by provincial and
territorial health plans. Health
Canada, however, provides direct primary care and
emergency services on reserves in remote and isolated areas where no
provincial services are available. More
precisely, the department operates 4 small hospitals, 77 nursing stations and
217 health centres.
Health Canada also provides community-based
health promotion and prevention services or funding for such services for
First Nations people living on reserves.
Regardless of residence (on or
off–reserve), First Nations people receive non-insured health benefits (NIHB)
funded by the federal government. These
benefits include drugs, medical supplies and equipment, dental care,
vision care, medical transportation, provincial health care premiums and
crisis mental health counselling.
Provincial and territorial governments are
responsible for delivering health services to Inuit, but delivery of health
services to Canada’s Inuit population varies with jurisdiction of residence.
In 1988, the federal government transferred responsibility for health
administration to the Government of the Northwest Territories.
With the creation of Nunavut, the Nunavut government assumed this
responsibility for the Nunavut region. The
federal government provides funds to the territorial governments to deliver
health programs for First Nations and Inuit including non-insured health
As a result of the James Bay and Northern
Quebec Agreement, the federal government transferred responsibility for Inuit
health services in northern Quebec to the government of Quebec then to Nunavik.
The Nunavik Regional Department of Health and Social Services
administers federal and provincial programs in that region.
In Labrador, the province provides health
services to all residents and the federal government provides funding to the
Labrador Inuit Health Commission through a transfer agreement and contribution
agreements for specific projects and for a range of federal programs including
non-insured health benefits.
Métis and non-status Indians are not
eligible for federal health programs. They receive medical services from
provincial and territorial governments on the same basis as other Canadians.
Métis and non-status Indians are not included under the Indian
Act and are not eligible for non-insured health benefits funded by the
The federal government responsibilities
with respect to First Nations and Inuit health services are carried out by
Health Canada’s First Nations and Inuit Health Branch (FNIHB) (formerly the
Medical Services Branch). FNIHB’s
overall responsibilities include:
the provision of community-based health
promotion and prevention programs to First Nations living on reserves and to
Inuit communities (including public health, health education and promotion, as
well as strategies to address specific health problems such as alcohol and
the provision of non-insured health benefits
(NIHB) to First Nations and Inuit people regardless of residence in Canada;
the provision of primary care and emergency
services in nearly 200 isolated and semi-isolated areas where no provincial
services are readily available;
public health services in over 400
funding addiction services through treatment
centres and addiction treatment workers.
Overall, the expenditures of the First
Nations and Inuit Health Program for 2000-01 were estimated at $1.3 billion.
About 53 percent or $677.6 million of this amount was devoted to
expenditures on community health services, 45 percent or $578 million to
non-insured health benefits, and 2 percent or $23.5 million to hospitals.
In his testimony, Mr. Potter outlined
several challenges faced by the First Nations and Inuit health programs.
These include: an increasing client base; a shortage of doctors and
nurses; providing service in remote and isolated communities; maintaining and
attracting physicians and nurses to work in isolated communities; difficult
access to some specialized services; significant cost increases associated
with drug benefits, medical technology and transportation; and increases in
the rate of chronic diseases that require long-term care and drug therapy.
Working to change the underlying social and
economic conditions such as poverty, inadequate housing and low levels of
education that are also important determinants of health and achieving better
coordination with the provinces were also identified as important challenges.
In addition to Health Canada, eleven other
federal government departments offer programs for Aboriginal people.
Total expenditures for these programs for 2001-02 are estimated at $7.3
billion. The vast majority of
this money (70 percent) falls under the budget of Indian and Northern Affairs
Canada (INAC) followed by Health Canada at 19 percent ($1.3 billion), Canada
Mortgage and Housing Corporation (CMHC) at 4 percent and Human Resources
Development Canada (HRDC) at 3 percent. A
number of other departments make up the remaining 3 percent.
Indian and Northern Affairs Canada’s
mandate includes social assistance programs, funding for elementary, secondary
and post-secondary education, on-reserve housing, child and family services;
and services on reserves such as homemaker services. INAC also funds infrastructure projects in Aboriginal
communities. These include water
and sewer services, environmental remediation, roads and bridges, fire
protection, electrification, education facilities and other community
Other federal departments are also involved
in the funding of a number of Aboriginal business development and workforce
The historic relationship between the
federal government and Canada’s Aboriginal peoples sets the context for
federal policy and initiatives in relation to Aboriginal health.
Table 5.2 outlines a number of events in this relationship.
In its brief to the Committee, the National Aboriginal Health
Organization (NAHO) explained:
The federal government’s policy
relationship with Aboriginal groups has seen significant change in the last
decade. As little as fifteen years ago, federal Aboriginal resources for
health and social programs were directed almost exclusively to First Nations
and Inuit communities; non-reserve groups received limited programs from the
federal government (examples would be off-reserve housing programs and the
Canadian Aboriginal Economic Development Strategy) and indeed these groups
were virtually invisible to the Canadian public. Today, the federal
government’s policy focus remains directed to First Nations and Inuit,
however, several Aboriginal-wide initiatives have been developed which also
involve the non-status, off-reserve and Métis populations.
Health Policy Events:
Peoples – Federal Government Relationship
Constitution Act, 1867
Gave the federal government
jurisdiction over “Indians and Land reserved for the Indians”
Enactment of the federal Indian
Supreme Court of Canada decision
Recognized that the term
“Indian” in the Constitution includes Inuit
Shift in health services
Responsibility for Indian health
services was transferred from Indian Affairs to the Department of
National Health and Welfare
Medical Services Branch (now the
First Nations and Inuit Health Branch)
The Medical Services Branch was
created within the Department of National Health and Welfare to
amalgamate Indian Health and Northern Health
Indian Health Policy
Goal: “to achieve an
increasing level of health in Indian communities, generated and
maintained by the Indian communities themselves”. Improvements to the
health status of the Indian population should be built on three pillars:
the traditional relationship between Indian people and the
federal government; and
the interrelated Canadian health system, with its federal,
provincial, municipal, Indian and private sectors.
Recommended methods of
consultation that would ensure substantive participation by First
Nations and Inuit people in the design, management and control of health
care services in their communities.
Constitution Act, 1982
Recognition of First Nations,
Inuit and Métis and enshrinement of existing Aboriginal and treaty
rights in the Canadian Constitution
Transfer Policy Approval
Federal Cabinet approved the
health transfer policy framework for transferring resources for Indian
health programs south of the 60th parallel to Indian control.
Supreme Court of Canada
Various Supreme Court of Canada
decisions with respect to the government’s fiduciary responsibility to
The Government of Canada
recognizes the inherent right of self-government as an existing right
within section 35 of the Constitution
Act, 1982. Health is one of the subject matters that could be
covered in self-government negotiations.
Report of the Royal Commission
on Aboriginal Peoples (RCAP)
Report made a number of
recommendations in relation to Aboriginal health. Aboriginal health and
healing systems should embody the following characteristics:
equity in access to health and healing services and in health
holism in approaches to problems and their treatment and
Aboriginal authority over health systems and, where feasible,
community control over services; and
diversity in the design of systems and services to accommodate
differences in culture and community realities.
Strength: Canada’s Aboriginal Action Plan --
Federal government response to the RCAP report
focuses on: Renewing the Partnerships with Aboriginal people;
Strengthening Aboriginal Governance; Developing a New Fiscal
Relationship; Supporting Strong Communities, People and Economies
The Committee was told that federal
Aboriginal health policy has followed a continuum that reflects developments
in both the Canadian health care system at large and the evolving relationship
between the federal government and Aboriginal people.
During the first half of the 20th century, federal
Aboriginal health initiatives focused on medical care, rather than on
providing comprehensive services to the First Nations and Inuit populations.
This included the operation of nursing stations, health centres and
hospitals. With the introduction
of universal Medicare, the provision of public health and preventative
measures rather than the delivery of direct health care became the main
emphasis of federal Aboriginal health activities, although Health Canada has
continued to provide primary health services in remote and isolated areas.
For the most part, however, federal Aboriginal health initiatives are
limited to First Nations and Inuit. Métis
and non-status Indians benefit from only a limited number of federal programs.
The federal Indian Health Policy 1979
established the general policy framework for the provision and payment of
health services by the federal government to First Nations and Inuit.
The stated goal of the Policy is “to achieve an increasing level of
health in Indian communities, generated and maintained by the Indian
communities themselves”. The
Policy provided that improvements to the health status of the Indian
population should be built on three pillars:
community development (socio-economic and cultural/spiritual) in order
to remove the conditions which limit the attainment of well-being;
the traditional trust relationship between Indian people and the
federal government; and
the Canadian health care system, with its federal, provincial,
municipal, Indian and private sectors.
Another important feature of the Policy was
the recognition that First Nations and Inuit communities could take over the
administration of their own community health programs.
To achieve this objective, in the mid-1980s the federal government
began to emphasize the transfer of control over health services to First
Nations and Inuit communities and organizations.
Table 5.3 shows the status of transferred
communities as of March 31, 2000 and the projected transfers to 2005. The
total number of eligible First Nations/Inuit communities is 599.
As of fiscal year end 1999/2000, a total of 276 (46 percent) of these
communities had signed a Health Services Transfer Agreement.
March 31, 2005
Health Canada, First Nations and Inuit Control, Annual Report,
1999-2000 (available at http://www.hc-sc.gc.ca/msb/pptsp/annual_e.htm#T3).
During the hearings, witnesses outlined a
number of jurisdictional and structural issues in relation to Aboriginal
health services that have the effect of impeding or denying access to
appropriate health care services.
barriers to the provision of health services to Aboriginal people exist on two
levels. The first barrier arises from the division of powers between the
federal and provincial governments. Provincial
governments provide equal access to health care services under the Canada
Health Act for all residents including First Nations living on reserves
and Inuit but take the position that the federal government is responsible for
certain health services to Aboriginal persons who are Indians under the Indian
Act (Status Indians). As a
result, witnesses indicated that health services not covered by the Canada
Health Act but otherwise provided by the provinces may or may not be
provided to First Nations and Inuit communities.
Other consequences of having two
jurisdictions involved in delivering health services include program
fragmentation, problems with coordinating programs and reporting mechanisms,
inconsistencies, gaps, possible overlaps in programs, lack of integration, the
inability to rationalize services, and impediments to developing a holistic
approach to health and wellness.
The second jurisdictional barrier stems
from the divisions among Aboriginal peoples that arise as a result of the Indian
Act. Because Métis and non-status Indians are excluded from the
legislation, they are not eligible for most federal programs. The NAHO and the
Métis National Council stressed before the Committee that lack of recognition
leaves the Métis and non-status populations in a jurisdictional void.
For example, Dr. Judith Bartlett noted:
There are no primary care services
specifically targeted to Métis and non-status Indian populations. (…) The
Métis and non-status are in a jurisdictional void. They, in fact, are
excluded from legislation, and this impacts on their eligibility for programs.
Similarly, Gerald Morin, President of the
Métis National Council, told the Committee:
Federal and provincial jurisdictional
disputes, cultural barriers and geographic isolation … impede our access to
the health care system. Métis communities are facing many of the same health
challenges as other Aboriginal communities but the difference is that Métis
health issues receive limited and scant attention from the federal government.
The fundamental issue at stake for the Métis is the unwillingness of
Health Canada to deal equitably and fairly with the Métis people as one of
the indigenous peoples in Canada.
Witnesses told the Committee about the
restrictive nature of the federal health transfer policy that transfers
control of federal health programs south of 60° to First Nations and Inuit
communities and organizations. It
was observed that the NIHB, a program comprising nearly half of Health
Canada’s funding to First Nations and Inuit, is not eligible for inclusion
in the transfer process.
Furthermore, the NAHO noted that Health Canada’s policy with respect
to the transfer of health services to Aboriginal organizations does not
include a framework that would “facilitate the integration of federal and
Again, this creates barriers to program rationalization and the
development of a comprehensive approach to Aboriginal health.
Witnessed also pointed out that structural
barriers arising from geography, isolation and small community size in rural
and remote areas have an impact on access to health services and the
comprehensiveness of available services.
High turnover rates for health workers, changes in visiting physicians,
language, and the lack of integration of traditional and western health
systems also constitute barriers. Witnesses
stressed that structural barriers are not just confined to rural and remote
areas – in urban settings barriers exist as well but may be secondary to
issues relating to the cultural appropriateness of care and lack of access due
Ron Wakegijig, a healer from the
Wikwemikong Health Centre, pointed out that because of the differences between
the concerns, issues and requirements of remote, isolated or semi-isolated
Aboriginal communities and more urbanized southern Aboriginal communities,
national policies developed for all Aboriginal people may not adequately
address specific regional concerns.
A number of witnesses emphasized to the
Committee that Aboriginal peoples are not a homogeneous group.
Inuit witnesses called for this distinctiveness to be recognized in the
delivery of health programs and research.
Pauktuutit Inuit Women’s Association of Canada stressed the
importance of meaningful involvement of Inuit in the development of programs
and policies that affect Inuit health. Pauktuutit
noted that often the terms “Aboriginal health” and “First Nations
health” have become one and the same; with the result that programming is
not based on the input and needs of Inuit.
The term “Aboriginal health” is
often misunderstood to be synonymous with First Nations Health. That
misinterpretation is a reflection of the lack of clear understanding of the
Indigenous people of Canada and their three distinct cultures.
For Inuit, the impact is most significant in the area of health
programming. Aboriginal Health
Programming continues to be First Nations focused, too often developed with
minimal, if any meaningful Inuit consultation and rarely reflective of the
specific linguistic and cultural needs of Inuit.
Further, it does not reflect the realities of program delivery in
isolated/remote communities nor acknowledge the differences in infrastructure
that exist between First Nations and Inuit communities.
Programs designed for First Nations are often imposed upon Inuit when,
in actuality, alternative, Inuit-specific, community based programming would
better meet the needs of Inuit community members. 
Witnesses involved in the hearings on
Aboriginal health stressed that the traditional concepts of health and
wellness in all Aboriginal communities are holistic, multifaceted and
The First Nations concept of wellness
encompasses the four realms of human existence. Some First Nations refer to
this concept as “the medicine wheel.” It is believed that well-being and
optimum health can only be achieved by addressing not only the physical
aspects of health, but also the emotional, mental and spiritual needs of an
individual. Those fundamentals make the First Nation view far more holistic
than the biomedical model.
medicine wheel illustrates that First Nations people believe that a person is
not only a body. If a person is to be healthy or
achieve wellness then each of the four aspects of their life must be in
balance. Appropriate attention must be given to each of the four aspects of a
person. Not only must one be balanced, one must live in a balanced, harmonic
community. Harmony must be addressed at all levels of existence and aspects of
life. The prevention of illness and the promotion of good health and healthy
lifestyles must be addressed through healthy communities and governments.
Aboriginal people define health and illness
in terms of balance, harmony, holism and spirituality rather than in terms of
the Western concepts of physical dysfunction and disease within the
individual. Aboriginal wellness
emphasizes that solutions to health will not be effective until all factors
having an impact on a problem are considered. Witnesses suggested that federal
Aboriginal health policy must develop a greater focus on prevention,
population health and a holistic approach to health that includes health
promotion and community-based program planning.
For example, the Assembly of First Nations observed:
Poverty, ill health, educational
failure, family violence and other problems reinforce one another. To break
this circle, all determinants should be addressed together, in a coordinated
strategy, not a piecemeal approach.
The Committee was told that much of the
current research has been focused on First Nations.
Dr. Judith Bartlett pointed to the paucity of Métis and Inuit-specific
research data. The President of
the Métis National Council confirmed that there is a lack of research, data
and information with respect to the health conditions and the demographics of
Métis people. The Inuit
Tapirisat of Canada cited the lack of Inuit-specific health information as a
key challenge. Pauktuutit Inuit
Women’s Association of Canada echoed this concern and noted that problems
arise when information from larger data sets is used in the context of another
Identifying new and emerging health
issues for Inuit is often complicated by a lack of “hard” data and by a
reluctance to use innovative anecdotal indicators in research methodology.
Inuit-specific health data is spotty at best and often extrapolated
from larger pools of Aboriginal data collected mainly in southern Canada.
For Inuit to adequately plan and prioritize health issues, for them to
identify changing trends in disease, data must be collected by Inuit about
Inuit and for Inuit. One prime example is HIV/AIDS surveillance data. Inuit statistics are extrapolations of data collected in two
provinces, Alberta and British Columbia, primarily large urban centres.
This has resulted in an overwhelming focus on and disproportionate
distribution of funding on prevention programs for “Aboriginal”
intravenous drug users, which have little, if any, relevance to Artic Inuit.
Witnesses also stressed the importance of
research on Aboriginal health issues that encompasses Aboriginal-directed and
controlled research. Dr. Jeff
Reading of the Institute of Aboriginal Health (CIHR) told the Committee:
Undertaking research can be a
significant determinant of health in its own right. It is a determinant of
health because people are able to take control over factors affecting their
lives. The context of native communities has been one where people outside the
community have managed control for a great period of time. Now people have the
opportunity to seize control and to start interpreting data about themselves.
When people participate in the creation
and understanding of knowledge about themselves, they take greater ownership
of their health problems and, in so doing, become active in terms of solving
those problems. Research is the
first step in terms of the drive toward self-determination and improved health
The Committee acknowledges that many
reports have been written and many suggestions made for changes to benefit
Aboriginal people. Repeatedly,
this particular population of 1.3 million Canadians has been designated by
international, national and regional bodies as the most needy in the country.
In spite of the breadth of effort being undertaken, the state of health
of Aboriginal Canadians and the socio-economic conditions in which they live
The Committee heard about the various
federal health strategies coordinated by Health Canada and the multiple
programs managed by Indian and Northern Affairs Canada.
Still, an enormous amount remains to be done if we are to reduce
disparities in health status and socio-economic disparities between Aboriginal
people and the general population. The
Committee feels that, given the wide range of programs that the federal
government currently manages and given its specific constitutional
responsibilities, it must develop population health strategies aimed
specifically at Aboriginal Canadians. These
strategies must include dealing with economic conditions, environmental issues
such as clean and safe drinking water, high-quality and culturally sensitive
health care, healthy lifestyle choices, etc. It
is also important, as suggested by Ron Wakegijig and others, to consider ways
to integrate traditional healing approaches to Aboriginal health with
mainstream health care.
Jurisdictional barriers should not be used
as an excuse to progress slowly in this field.
The Committee believes that these barriers can be overcome rapidly, and
that all levels of government – federal, provincial, territorial, municipal,
band and settlement – must develop a comprehensive plan that could meet the
needs of all Aboriginal people in Canada.
The federal Minister of Health should play a leadership role in
coordinating such a plan.
The Aboriginal population is young and
growing. It is imperative to
develop programs that are sustainable in the long-term period.
The Aboriginal community is also diverse.
Programs must be designed in a way that accommodate differences in
culture and community realities.
The Committee believes that undertaking
research on the health of Aboriginal people can provide useful information on
how to improve service provision and health outcomes.
The Committee welcomes the new Institute on Aboriginal Health at the
CIHR and believes it is essential that it be provided with a sufficient level
care system is a labour-intensive industry.
About one in ten employed Canadians work in the health care sector.
Many more help to care for their friends and family members.
Therefore, our system depends on having a steady supply of
appropriately distributed, well-trained and experienced health care providers
and committed volunteer caregivers. (The issues concerning volunteer or
informal caregivers are presented in more detail in Chapter Nine).
A complex mix of health care providers –
comprising more than 30 provincially regulated professional groups –
delivers care to Canadians. Table
6.1 shows the total number of licensed health care providers per 100,000
Canadians and the percentage change in these numbers over a 10-year period.
HEALTH CARE PROVIDERS IN CANADA
(Number Per 100,000 Canadians and Percentage Change)
Source: CIHI, Health Care in Canada,
Nursing is the largest health care
profession. In 1998, there were
7% fewer registered nurses and 17% fewer licensed practical nurses than in
1989. Doctors are the third-
largest group of regulated health care providers.
The number of physicians per Canadian in 1998 was about the same as ten
years before, with only a slight decrease of about a half percent.
Other categories of health care providers (except optometrists)
substantially expanded their workforce over the same period.
Although precise data are not available, an army of informal
(volunteer) care providers provide some form of care to someone in their home
with a long-term physical or mental illness or who is frail or disabled.
Information from CIHI (2001) suggests that the number of informal
caregivers has increased over the past decade.
There are no straightforward answers to the
question of how many people are currently needed in each field, and there is
much less certainty with regard to future requirements.
Nevertheless, talk of a ‘crisis’ in health care has a good deal of
plausibility in relation to human resource issues.
This is particularly true with regard to the situation facing
registered nurses (RNs) in Canada. But there are also shortages of other health care providers,
in areas ranging from laboratory technologists to pharmacists.
Although it is more difficult to assess the
overall situation with regard to physicians, there is nonetheless a
long-standing problem of geographical distribution of physicians, with all
rural and remote areas having great difficulty recruiting and retaining both
general practitioners (GPs) and specialists. The geographic maldistribution of
physicians is discussed in more detail in Chapter Ten.
As well, certain specialties are experiencing serious shortages.
Without an adequate supply of providers,
health care will simply not be available to the extent that Canadians expect
and deserve. Questions concerning
the supply, retention and management of human resources in health care are
complex, broad and often overlapping, but they are of paramount importance in
the context of ensuring the sustainability of Canada’s health care system.
Many of the key issues, such as the method
and level of remuneration of health care providers, fall largely outside the
purview of the federal government. There
are nonetheless other concerns - such as inter-provincial mobility,
immigration, research funding, and taxation - in which federal policy plays a
central role. Because of the
interaction between all these factors, it is important to get as complete a
picture as possible of human resource issues so that the impact of possible
policies at the federal level can be properly understood and assessed.
The extent to which there is a looming
overall shortage of physicians in Canada remains a subject of debate.
Figures recently released by CIHI indicate that the number of
physicians has increased in Canada over the past five years, from 54,918 in
1996 to 57,803 in 2000.
However, while the total number of specialists increased by 7.4
percent, the number of family physicians only grew by 3.2%.
Since the Canadian population grew by 3.5 percent over the same period,
the number of family physicians on a per capita basis actually declined
slightly (from 95 per 100,000 population in 1996 to 94 in 2000).
Several witnesses stressed the importance
of looking beyond the aggregate numbers.
Thus, despite the increase in the total number of specialists,
witnesses indicated to the Committee that certain specialties are experiencing
shortages. For example, Dr.
William Dalziel of the University of Ottawa estimated that there is a serious
deficit of geriatricians. Similarly,
Dr. John Radomsky of the Canadian Association of Radiologists told the
Committee that Canada currently has a shortage of about 200 radiologists, and
We simply do
not have the manpower to provide the service. In my own practice, we have had
to curtail service… to two small institutions because we do not have the
manpower to provide them the service on-site. Patients have to travel. They
are inconvenienced. In many cases they just do not do it.
Witnesses told the Committee that
physicians are already straining under the workload.
Dr. Peter Barrett, President of the Canadian Medical Association (CMA),
pointed out that “the average physician in Canada is currently working 53
hours per week and an additional 25 hours per week while on call.”
Of even greater concern were the approximately 2,000 physicians who had no
shared call, and were therefore “literally on call 24 hours per day, seven
days per week, every day, every week, for years at a time.”
Furthermore, the aging of the physician
population means that many doctors are no longer willing or able to work the
long hours that have become the norm. Dr. Barrett indicated that the average
age of physicians rose from 46.4 to 47.5 between 1996 and 2000, and he added
that “by 2024, 40 per cent of all active physicians will be over the age of
At the same time, women have made
tremendous strides in changing the profile of the medical profession.
Since the mid-1990s women make up over half of the medical students in
and the percentage of practising female doctors increased from 25 to over 29
percent of the total between 1993 and 2000.
The Task Force on Physician Supply of the Canadian Medical Forum
predicts that, by 2015, women will make up 40% of the physician supply.
However, data also indicate that female physicians practise fewer hours
than their male counterparts, averaging 48.2 hours per week compared to the
male average of 55.5 hours per week. 
As Dr. Barrett pointed out:
traditionally are more caring individuals and have tended to want a better
balance in life. We are not seeing that only from the women, though. We are
also seeing that from our younger graduates.
clear agreement during the Committee’s hearings on one subject: the persistent geographic maldistribution of physicians
across the country. Over the past
two decades, studies have repeatedly concluded that this longstanding problem
has led to shortages of physicians in rural and remote areas.
The problem seems to be getting worse, as
an increasing number of smaller and medium-sized communities are finding it
difficult to ensure a proper supply of physicians. As of October 1999, for
example, 99 communities in Ontario had been designated as underserviced and
were looking for a total of 534 physicians.
Many factors have been identified as contributing to the difficulties
in encouraging physicians to locate in underserved areas, including the heavy
workload, the lack of training in skills needed for rural medicine,
professional isolation and lack of interest in rural lifestyle.
The Committee heard evidence suggesting
that physicians setting up their practices are more likely to choose rural or
remote areas if they come from those backgrounds or if their training has
exposed them to the positive challenges associated with locating in these
areas. Dr. Thomas Ward, chair of
the Federal/Provincial/Territorial Advisory Committee on Health Human
Resources, noted that “the single most important determinant as to whether
an individual will work in a small community is if they are from a small
The supply of physician resources in rural
Canada is discussed in more detail in Chapter Ten.
During the Committee’s hearings,
witnesses discussed the issue of whether enough students are being admitted to
Canada’s medical schools.
In 1991, a report by Barer and Stoddart
recommended that enrolment in Canadian medical schools, along with positions
in postgraduate training positions, be decreased by 10% in order to deal with
a perceived unwarranted increase in physician supply.
Despite the report’s admonishments that this recommendation not be
implemented in isolation from the others it proposed
(53 in all), policy-makers did precisely that.
As a result, according to data from the Association of Canadian Medical
Colleges, the size of first year classes in medical colleges has declined by
16 percent since 1991.
The first-year enrolment in 1997-98 of
1,577 students, or approximately 1 per 19,000 citizens, put Canada well behind
other industrialized countries such as the United Kingdom (1 per 12,200
citizens) or Australia (1 per 13,500). According
to Dr. Hugh Scully, President of the Task Force on Physician Supply, Canadian
Medical Forum: “by 1997, there was less opportunity for a Canadian to go to
medical school than for any person in any other developed country in the world
for its population.”
Although by early 2001 announced increases to undergraduate enrolment
totalled 228 new places (a 14 percent increase over 1998) this is still below
the entry level of 1983 (the peak year).
While recognizing that “that there has
been more movement on the part of the medical schools and the establishment in
the last 18 months than in the last 20 years,”
Dr. Scully insisted that more progress cannot be made unless additional
resources are put into the system, telling the Committee that:
If we are to have the teachers to do
the work and the resources, both capital and physical, that we need, there
needs to be some infusion. We think that the federal government can play a
significant role in partnership with the provinces and the territories.
Canada also does not offer as many
postgraduate training positions as other countries, with 100
provincially-funded positions for each 100 graduates (compared to 129/100 in
the United States and 140/100 in Britain).
Dr. Scully pointed out that “we once had a much better capacity than
we have at the present time to validate the international graduates who were
In the past, Canada has been able to rely
on recruitment from abroad to fill some of the gaps. International medical graduates (imgs)
have made significant contributions to Canadian health care.
Currently, almost 25 percent of Canada’s physicians received their
undergraduate (MD) training outside Canada.
Imgs are unevenly
distributed geographically and by specialty, accounting for only 12 percent of
supply in Quebec but about 50 percent in Saskatchewan.
One third of pediatricians, but only 22% of family practitioners are imgs.
The United Kingdom has been the major
source of imgs.
However, other countries now face many of the same shortages that
confront our health care system, and there does not seem to be much sense to
countries endlessly poaching each other’s highly trained health care
professionals. Dr. Scully
insisted on this point:
Canada traditionally would draw upon
the U.K., South Africa, and some of the European countries for its medical
graduates. That source has in large part stopped, not all together. Those
countries are working earnestly to try to retain their own physicians and make
it attractive for them to stay. The sources that we have had are not there.
Rising tuition fees constitute a major
barrier to medical enrolment. Dr.
Barrett stated that:
(…) tuition deregulation has meant
that tuition for our students is becoming prohibitive. If we do not do
something soon, it will only be the sons and daughters of wealthy Canadians
who will be able to go to medical school and choose a career in medicine.
The Committee was told that rising tuition
fees are of great concern for students from rural Canada. For example, Dr. Thomas Ward, Chair of the F/P/T Advisory
Committee on Health Human Resources, stated:
We have seen
a dramatic swing in the past four years, in our province, in the distribution
of people coming into the medical school. As university tuition has gradually
risen, university medical schools are a cash cow for most universities, quite
frankly. We have seen that the percentage of students coming from rural Nova
Scotia is dropping steadily.
Dr. Barrett expressed similar concerns in
relation to the recruitment of medical students from Canada’s Aboriginal
I will give
you an example from my province of Saskatchewan, where we have a huge
Aboriginal population. The best way to deliver health care to them would be,
especially in consideration of their culture, to have First Nation's health
care providers. However, right now our system has barriers that hinder their
receiving the necessary education. That is why we need to look at the whole
area of post-secondary education. In particular in consideration of tuition
deregulation, we must examine who we are educating today.
Another controversial issue concerns the
‘brain drain’ of physicians, particularly to the United States.
Table 6.2 gives figures for the departure and return of physicians.
During the period between 1996 and 2000, the number of physicians
leaving the country declined significantly, from 1.3 percent of the total
physician supply in 1996 to 0.7% in 2000.
Of these physicians, the majority were male, specialist physicians.
Almost half received their M.D. within the past 10 years.
The number of physicians who returned from abroad increased somewhat
over the 1996-2000 period. Overall,
fewer doctors are leaving and more are entering Canada (except for 2000).
However, Canada still experiences a net loss year after year.
The international migration of physicians
remains a major concern for many witnesses.
Dr. Barrett said that “for every 19 physicians that go south, one
comes north,” while Dr. Scully pointed
out that “we continue to lose two medical class school equivalents a year as
a net loss to the United States.”
Physicians Moving Abroad and Returning to Canada,
Source: CIHI, Supply, Distribution and Migration of Canadian
Physicians, 2000 Report, Executive Summary,
9 August 2001 (available at http://www.cihi.ca).
While clearly many factors clearly
influence decisions by Canadians to relocate elsewhere, it has sometimes been
contended that Canada’s more onerous tax regime drives high-earners to seek
more favourable circumstances south of the border.
Surveys among doctors, however, indicate that income is usually not the
prime motivator for leaving Canada, and that the conditions under which they
are able to practise their profession rank higher as a factor.
Dr. Scully argued very much along these lines:
The money is no different in Alberta
than North Dakota. It is not a question of money. It is the facility to take
care of your patients’ welfare. If we want to attract and retain physicians,
we need to work together to ensure that the facilities are there so that
physicians, nurses and others can work to provide the services that are needed
In the same vein, Dr. Barrett stated:
Like other sectors of the economy, if
we are going to compete and succeed, we must provide an attractive environment
to not only retain but repatriate the physicians who have left. If we are
serious about a world class health care system in Canada, we must provide an
environment that will attract world-class people and retain the world class
people that we train.
Overall, all witnesses agreed that what was
needed was a comprehensive human resources plan. As Dr. Scully pointed out, “there are no quick answers or
quick fixes.” In Dr. Barrett’s
We could start with a national strategy
because it is a national problem. I realize a lot of health care is delivered
provincially and territorially. First and foremost, we need a national plan.
Nurses constitute the largest group of
health care providers in Canada, making up almost two-thirds of the total.
There are three regulated nursing groups: registered nurses (RNs),
licensed practical nurses (LPNs – also known as Registered Nursing
Assistants and Registered Practical Nurses), and Registered Psychiatric Nurses
(RPNs). Most of the available
data refers to the situation of RNs. There
are two routes to qualification as an RN: (i) diploma programs offered at
community colleges, and (ii) baccalaureates of Science in Nursing at the
university level. Around 90% of
nurses employed in nursing have a basic diploma education.
Some provinces recognize an additional extended classification of
nurses, usually referred to as nurse practitioners, but there are no national
standards in place, and the term is not a protected designation.
Nurses work in a great variety of settings
and perform a wide array of tasks requiring a considerable diversity of
skills, ranging from assisting in the treatment of acutely ill patients in a
hospital setting, to planning and monitoring home care programs, to organizing
and delegating workloads. Recent
changes in the organization and delivery of health care have had a significant
impact on the types of work being done by nurses and on the numbers of nurses
available to perform them.
With the shift towards shorter hospital
stays, nurses are treating more acutely ill patients as well as being asked to
perform many tasks that might have been done previously by other hospital
staff. For example, a recent
study indicates that in Canada over 42% of nurses report performing
housekeeping duties, while a similar number (43.6%) report that such essential
nursing tasks as comforting or talking with patients are being left undone.
Trends in health care technology also mean that nurses must accomplish
more complex tasks, under great stress and with shrinking resources. In this
regard, Kathleen Connors, President of the Canadian Federation of Nurses
Unions, told the Committee that nurses:
(…) want to nurse in the way that
they were educated to nurse. Not only do they want to perform the physical
parts of the care, they also want to teach and take the time to sit on the
side of the bed of someone who needs to be supported and comforted. They want
to counsel, nurture and do all those things on which it is difficult to place
a monetary value.
reports a decline of 7.2% in the number of RNs (per 100,000 Canadians)
employed in nursing between 1989 and 1998, while the number of LPNs declined
by 17% over the same period (see Table 6.1).
According to the Canadian Nurses’ Association, there is looming
crisis in the supply of qualified nursing personnel.
The Association forecasts a shortfall of at least 59,000 nurses in
Canada by 2011, but that this shortfall could be as high as 113,000 if all the
needs of an aging population are taken into account (Table 6.3).
number of employed Registered Nurses needed
to adequately meet demands in 2011
Projected level of demand
Source: Statistical picture of the
past, present and future of RNs in Canada, CNA, 1997.
While witnesses acknowledged that the
nursing shortage is worldwide in nature (with only Hong Kong registering a
surplus of nurses), they also indicated
that the severity of the situation facing nursing in Canada had its origins in
the cost containment strategies that were initiated by all governments across
the country in the early 1990s. For this reason, they unanimously recommended
that more funds be invested in the health care system so that the shortage in
nursing resources could be redressed. For
example, Régis Paradis, President of the Ordre des infirmières et infirmiers
auxiliaires du Québec, argued that “even if the federal government had to
take various steps to put its fiscal house in order, we believe that the cuts
have been too drastic, carried out without meaningful consultation and also
without taking into account the real needs of the public.”
Similarly, Sandra MacDonald-Remecz, Director of Policy, Regulation and
Research at the Canadian Nurses Association (CAN), affirmed to the Committee:
If I were to leave with you any
message, it is that I believe that investing is extremely important. We need
to invest so that we can have the kind of qualified, competent worker within
our health system. If you do not have that competent, qualified person, you do
not have a health system.
The shortage of nurses has important
consequences both for the delivery of health care and for the working
conditions faced by health care providers who have to try to cope with fewer
available people. Kathleen
Connors noted that “Canada is suffering a nursing shortage that regularly
closes emergency rooms and shuts operating rooms,”
Shifts piling on top of each other take
their toll on nurses who might be taking care of your mom or your child. In
some cases, we are doing so having worked more than 60 hours in the week…
Flight attendants have mandatory time off, but nurses do not. In the end, that
is not good for nurses and it definitely is not good for those for whom we
Despite the overall shortage of nursing
personnel, full-time employment for nurses has become less common.
Sandra MacDonald-Remecz told the Committee that “the period that we
have gone through saw a significant move to part-time and casual status.”
In fact, the number of nurses working part-time increased by almost 10%
between 1990 and 1997 while those in full-time positions declined by about
8.5%. There was also a 37.5%
increase in the number of nurses working as casuals over the same period.
While it is no doubt true that some nurses prefer part-time work,
nonetheless about 19% of nurses employed part-time in 1998 held down more than
one job, and very few nurses voluntarily choose casual work.
The “casualization” of the workforce
has also meant that it is increasingly difficult for new nursing graduates to
secure permanent positions. This
tends to reduce the attractiveness of nursing as a career choice and to
prolong the apprenticeship period of new graduates.
In this regard, Kathleen Connors pointed out that:
The situation facing those younger
nurses is that of casual or part-time employment opportunities – working for
several employers, instead of working full-time for one employer. In 1998, 48
per cent of all nurses in Canada were working part-time. It just should not
According to witnesses, this contributes to
a situation where 3 in 10 nurses leave the profession in the first five years
This combination of an overall shortage of
nursing personnel and under-utilization of trained nurses is also evident with
regard to other categories of nursing personnel. For example, Linda Jones from the Nurse Practitioners
Association of Ontario told the Committee that “of our 401 graduates, 200 of
them are under- or poorly employed as nurse practitioners.”
Similarly, Régis Paradis indicated that, “we (…) consider that the
skills of Quebec auxiliary nurses are not being fully used,” and that “the solution
to the problem of work overload, in addition to putting more money into the
system, lies partly in making more use of auxiliary nurses.”
But the deterioration in working conditions
for nurses extends beyond the full utilization of the different categories of
nursing personnel. According to
CIHI, nurses account for over 75% of workplace injuries in health care,
stemming mainly from lifting and moving patients.
During her testimony, Kathleen Connors indicated that:
(…) nurses are sicker than any other
worker in the country. In fact,
8.4 percent of nurses are absent from work due to illness each week. That is twice the national average.
Witnesses also raised concerns that there
are many ways in which nurses are not being accorded the respect they deserved
for their essential contribution to the health care system.
Amongst the issues that have been raised as critical to retaining
nurses in the profession are appropriate workload, adequate continuing
education, career mobility, flexible scheduling and deployment, professional
respect and good wages. Witnesses argued that what is needed to retain nurses
in the profession in Canada is a comprehensive approach to ensuring a healthy
work environment that also allows nurses sufficient autonomy in carrying out
their duties and room for ongoing professional development.
The Canadian Nurses Association identified seven areas of action needed
to retain nurses:
Improve work design
Facilitate use of full scope of practice
Provide support for professional development
and continuous learning via taxes, training and time
Identify career opportunities and offer
Support flexible scheduling
Provide accessible professional supports
Improve access to research on clinical
disease issues and provide time to review and stay up-to-date.
The Committee was told that there are many
difficulties in recruiting enough young people to train as nurses.
Witnesses contended that nursing, which remains an overwhelmingly
is no longer as attractive a career option for young women entering university
as it was for the previous generations. Sandra
MacDonald-Remecz noted that “we have seen a 50 per cent reduction in the
number of graduates in nursing over the last 10 years.”
Figures indicate that not only are fewer
new nurses entering the profession each year, but those that do are older than
previously. The number of new nurses graduating each year was in the 10,000
per year range in the 1970s and in the 8,000 per year range in the 1980s.
Since then, each class has become increasingly smaller and only 5,500
nurses graduated in 1995. Witnesses
pointed to the solution adopted in the Republic of Ireland, where they waived
all tuition fees for nursing students, as being worthy of emulation.
The issue of continuing education for
nursing was also raised at the Committee’s hearings.
The lack of opportunity for ongoing education was pointed to as part of
the problem explaining the attraction of new graduates in nursing to the
United States. While no exact
figures are available, some media reports have suggested that as many as
20,000 Canadian nurses have been recruited by American hospitals. According to Sandra MacDonald-Remecz:
(…) when we look at why the Americans
are so successful in recruiting our new graduates, we see that it is because
they promise continuing education opportunities right from the time they sign
One way of facilitating ongoing education
was suggested by Kathleen Connors:
(…) one of the issues that we
continue to promote and hope that there will be support for, is the use of
employment insurance dollars. There is a surplus. If skilled trades can access
EI dollars to continue to advance their education, why can nurses not do the
same thing? We need to look at that. Why does EI prevent access of dollars for
Another solution was proposed by Ms.
Signing bonuses are another incentive -
which, in a field like health care it sounds almost heretical to be taking on
that kind of orientation. However, it is something that many organizations are
realizing that they may need to do. In other words, we need to be more
aggressive and recognize that people will not just naturally come into the
Many other health care providers, from
pharmacists to laboratory technologists to ultrasound technicians, have voiced
similar complaints to the ones expressed by physicians and nurses over human
resource shortages and deteriorating working conditions throughout Canada’s
health care system.
example, the Canadian Society for Medical Laboratory Science (CSMLS) predicts
a nation-wide shortage of general medical laboratory technologists within the
next 5 to 15 years. Moreover,
medical laboratory technologists are aging:
12% of the current workforce will be eligible to retire in 5 years,
15.8% in 10 years and another 16.6% in 15 years.
By the year 2015, 44.4% of the medical laboratory workforce will either
have retired or will be eligible to retire.
In its brief, the Society stressed that the number of training
positions would have to be increased significantly to avert the shortage of
technologists. Medical laboratory
technologists also stressed the need for ongoing training to enable them to
operate new high-tech equipment. Moreover,
the medical laboratory workforce is also experiencing high levels of burnout
and fatigue. Finally, the
establishment of a national data base was recommended to develop accurate
projections of future human resource requirements in health care.
The Canadian Pharmacists Association also
pointed to a current shortage of pharmacists.
This shortage is not unique to Canada, but is a problem faced in many
countries including the United Kingdom and the United States.
The low supply of pharmacists translates into increased numbers of
vacancies, longer times to fill vacancies, increases in overtime hours, and
wages rising in excess of the cost of living.
A recent study suggests that well over 2,000 additional pharmacists
could readily find work in Canada.
In the context of the growing evidence of drug-related complications,
an aging population, and rising public expectations, it is anticipated that
pharmacists will be increasingly valued and demanded for their knowledge,
skills, and cost-effective contribution to the health care system.
The study also mentions that currently available information offers an
incomplete picture of the labour market for pharmacists.
Chiropractors’ representatives told the
Committee about their particular situation.
Chiropractic services are not considered as medically necessary under
the Canada Health Act. Only
a few provinces provide public insurance for chiropractic services.
The Committee was told that there are over 5,000 practising
chiropractors in Canada and that approximately 4.5 million Canadians use their
services every year. In its
brief, the Canadian Chiropractic Association stated that chiropractors are not
being utilized by Canada’s health care system in the most effective way.
There are policy and legislative barriers to chiropractic services
which result in inequitable resource allocation irrespective of patient
choice, efficacy or cost-effectiveness. For
example, chiropractors do not have hospital privileges, they cannot refer
their patients to publicly supported X-ray facilities or diagnostic
laboratories, or render services to their patients who may require
Testimony before the Committee by health
care providers, particularly physicians and nurses, clearly indicated that a
more rational and efficient use of human resources requires a rethinking of
the organization and the funding of primary health care delivery in Canada.
“Primary health care” refers to the
first level of care, and is usually the first point of contact that people
have with the health care system. Primary
health care settings support individuals and families to make the best
decisions for their health. Primary
health care services need to be:
accessible to all consumers;
provided by health care professionals who
have the right skills to meet the needs of individuals and communities being
accountable to local citizens through
Multidisciplinary teamwork must therefore
be a vital part of primary health care. The
goal of this teamwork is not to displace one health care provider with
another, but rather to look at the unique skills each one brings to the team
and to coordinate the deployment of these skills.
Clients need to see the health care provider who is most appropriate to
deal with their problem.
The way in which health care is currently
delivered in Canada does not normally reflect a primary health care philosophy
(although Community Health Centres are an example of organizations that do
deliver health services using such a philosophy). Health services are often not coordinated, nor are they being
provided by the most appropriate practitioner; as well, the knowledge and
skills of many practitioners are not being fully utilized.
The need for significant changes to the way
primary health care is delivered has been the principal thrust of the
recommendations of a number of provincial health care reviews, notably the
Sinclair Commission Report in Ontario, the Clair Commission Report in Quebec
and the Fyke Commission Report in Saskatchewan. In fact, the importance of changing the way primary health
care is delivered is so widely established that, in September 2000, provincial
and territorial governments all agreed to accelerate primary health care
The federal government is actively
supporting the efforts of provinces and territories in primary health care
reform and renewal. More
precisely, it has established a Primary Health Care Fund of $800 million over
four years (2000-2004) to support the transitional costs of implementing
systemic, large-scale, primary health care initiatives.
Some 70% of the funds are to be devoted to major provincial and
territorial reforms, while the remaining 30% is going to support national and
multi-jurisdictional initiatives related to advancing primary health care
Dr. Thomas Ward indicated that Canadians
and physicians support the idea of moving towards multidisciplinary primary
There was a survey last fall in which,
when Canadians were asked if they would rather receive their care from a
family physician or from a primary care team that included a family physician,
their response was 4 to 1 in favour of the team. They would much rather have a
team of health care providers. Our vision for the future is full integration
wherever primary health care is provided through practising within
The Committee was also told that reform of
primary care is clearly central to the possibility for the full deployment of
the additional skills possessed by nurse practitioners.
Primary health care nurse practitioners are experienced registered
nurses with additional nursing education that enables them to provide
individuals, families and communities with health services in the areas of
health promotion, disease and injury prevention, cure, rehabilitation and
support. Their skills include the
ability to: provide health screening activities such as PAP smears; to
diagnose and treat minor illnesses such as ear and bladder infections or minor
injuries such as sprains; to screen for the presence of chronic disease such
as diabetes; and to monitor people with stable chronic disease such as
hypertension. They function
within the full scope of nursing practice and are neither second-level
physicians nor doctor’s assistants. As
Linda Jones, from the Nurse Practitioners Association of Ontario, said:
A very important…point is the lack of
public understanding of the role, impacts and utilization of nurse
practitioners. If we are seen as physician replacements – you cannot see
your family doctor, you must see your nurse practitioner instead – that will
not enhance or increase public acceptance of us.
While nurse practitioners are an important
part of primary health care reform, there remain considerable barriers to
their full integration into the system of primary health care delivery.
Ms. Jones pointed out that, in Ontario:
The existing legislation, although we
are incredibly excited about the fact that we now have our own autonomy to do
our role, leaves us with barriers. For example, the public hospitals act does
not allow us to perform our role in hospitals.
The Committee was told that the barriers
are not exclusively legislative or organizational, however. They are also created by the way that money is distributed
throughout the health care system, and, in particular, by the overwhelming
reliance on fee-for-service payment as the main method for remunerating
physicians. Fee-for-service tends
to actively discourage physicians from promoting teamwork, as their individual
remuneration depends on the number of patients they see.
In her testimony, Linda Jones pointed to another way that
fee-for-service payment prevents full collaboration amongst health care
(…), although we have skills and
knowledge to refer to medical specialists, the current payment system under
OHIP does not give a specialist the full consulting fee if the referral comes
from nurse practitioners. Therefore, they decline our referrals.
The main alternatives to fee-for-service
payment are salary- and capitation-based systems, where physician practices
are remunerated based on the number of registered patients.
William Tholl, Secretary General and Chief Executive Officer of the
Canadian Medical Association (CMA), told the Committee that physicians are
willing to consider other forms of remuneration:
The CMA would suggest, as I would also
suggest, that the form of payment should follow the functions that you
identify for the physician in the system. Clearly, physicians and other health
professionals working in rural and remote areas have a different function in
the system as compared to those that work in downtown Toronto.
The Committee is convinced that addressing
the issues relating to human resources in health care must be amongst the top
health care policy priorities for all levels of government.
What is needed is a country-wide, long-term, made-in-Canada, human
resources strategy. The federal
government could play an important role in coordinating and implementing such
a strategy. Of course, not only
do the provinces and territories have the responsibility for the delivery of
health care to their populations, they are also responsible for education and
training. The challenge is
therefore to find a way to develop such a strategy in a manner that is
acceptable to the provinces and territories.
In the past, the federal government has
contributed capital funds toward the creation of new health services training
programs, notably in the 1960s when it was involved in the expansion of a
number of medical schools. The
federal government has also contributed to training programs for some health
professionals under the various federal training programs which have existed
over the years. Moreover, the
federal government, through its support for such institutions as the Medical
Research Council and now the Canadian Institutes for Health Research, has
helped support graduate students pursuing health research for more than 40
It is important that the federal government
continue this involvement in order to help resolve the many health care human
resource challenges facing the country. This
includes assisting the provinces in their efforts to reform primary health
care, because ways of effectively deploying human resources are intimately
tied to the reorganization of primary health care.
David Cheal, “Aging and Demographic Change,” Canadian Public Policy.
Vol. XXVI, supplement 2, August 2000, p. S110.
Statistics Canada, CANSIM, Matrix 6367.
Réjean Lachapelle and Jean-Marie Berthelot, Brief to the Committee, 21
March 2001, p. 2.
Abby Hoffman (7:19).
Byron G. Spencer, Brief to the Committee, 22 March 2001, p. 7.
These four schools of thought are well summarized in: Canadian Medical
Association, In Search of Sustainability: Prospects for Canada’s Health
Care System, August 2000.
Conference Board of Canada, Brief to the Committee, 21 March 2001, p. 5.
William Robson, Will the Boomers Bust the Budget?, Brief to the
Committee, 21 March 2001.
Dr. Michael Gordon, NACA, Brief to the Committee, 21 March 2001, p. 5. In
fact, a number of factors influence the average length of stay in hospital
including advances in surgical and other procedures, the greater range and
efficacy of available drugs, as well as more sophisticated approaches to
Byron Spencer, Brief to the Committee, p. 1.
See, for example, a report by the Office of the Auditor General of Canada, Population
Aging and Information for Parliament: Understanding the Choices, Chapter
6, 1998 Report.
William Robson (3:5). In this
report, the testimony received by witnesses printed in the Minutes of
Proceedings and Evidence of the Standing Senate Committee on Social Affairs,
Science and Technology will be hereafter referred to only by issue
number and page number within the text.
Byron Spencer (3:30).
Byron Spencer (3:16).
Jean-Marie Berthelot (2:11).
Jean-Marie Berthelot (2:10).
Lachapelle and Berthelot, Brief to the Committee, p. 4.
Rob Brown (2:15).
Abby Hoffman (7:7).
Dr. Michael Gordon (2:39).
Health Canada, Brief to the Committee, slide 6.
Dr. Michael Gordon, Brief to the Committee, p. 2.
Byron Spencer (3:36).
Dr. Michael Gordon (2:38).
Dr. William Dalziel (3:18).
Dr. William Dalziel (3:12).
Dr. William Dalziel (3:10).
William Robson (3:7).
Byron Spencer, Brief to the Committee, p. 5.
Spending on drugs reported by the CIHI includes prescription drugs, OTC
products and personal health supplies, but does not include drugs dispensed
in hospitals and other institutions.
Report of the Federal/Provincial/Territorial Task Force on Pharmaceutical
Prices, Drug Prices and Cost Drivers
1990-1997, April 1999, pp. 13-14.
 PMPRB, Annual
Report 2000, p. 15.
Canadian Pharmacists Association, Health
Care Delivery, Optimizing Drug Therapy and the Role of the Pharmacist,
Brief to the Committee, March 2001.
 Dr. Roger A. Korman
A description of provincial cost controls can be found in the Institute of
Health Economics Working Paper 00-2,
Public Policies Related to Drug Formularies in Canada: Economic Issues
and Devidas Menon, “Pharmaceutical Cost Control in Canada: Does It
Work?”, Health Affairs, Vol. 20,
No. 3, May/June 2001.
 PMPRB (2000), p. 18.
Prices and Cost Drivers 1990-1997 (1999), p. 30.
p. 34. Nova Scotia was not included.
The Fraser Institute, “Prescription Drug Prices in Canada and the United
States,” Public Policy Sources,
Prices and Cost Drivers – 1990-1997 (1999), p. iii.
Report of the Federal/Provincial/Territorial Task Force on Drug Utilization,
Drug Utilization in Canada, April
1999, p. 1.
 Dr. Robert Coambs (4:9).
Dr. Roger A. Korman (4:17).
 Canadian Association of
Gerontology, Policy Statement: Seniors
and Prescription Drugs, 1999, (http://www.cagacg.ca/english/pubs/pol-drugs.htm).
Coambs, Robert B., Ph.D. et al., Review
of the Scientific Literature on the Prevalence, Consequences, and Health
Costs of Non-Compliance and Inappropriate Use of Prescription Medications in
Canada, PMAC, 1995.
 Dr. Jeffrey Poston
Ms. Barbara Ouellet (4:20).
 Dr. Jeffrey Poston
 Canadian Life and Health
Insurance Association, Drug Expense Insurance in the Canadian Population,
The summary description of government and private plans has been taken from
information contained in the study Canadians’ Access to Insurance for Prescription Medicines, Applied
Management in Association with Fraser Group, Trisat Resources, Study
submitted to Health Canada under the Health Transition Fund, March 2000.
Canadians’ Access to Insurance for
Prescription Medicines, Executive Summary Applied Management in
Association with Fraser Group Trisat Resources, Study submitted to Health
Canada under the Health Transition Fund, March 2000.
These conclusions are summarized in the study’s Executive Summary.
 Robyn Tamblyn, et al.,
Evaluation Report of the Impact of
Prescription Drug Insurance Plan, Summary, March 1999.
 Dr Robert Coambs (4:21).
 Palmer d’Angelo
Consulting Inc., National Pharmacare
Cost Impact Study, September 1997.
Dr. Joel Lexchin, A National
Pharmacare Plan: Combining Efficiency and Equity, Canadian Centre for
Policy Alternatives, March 2001.
41st Annual Premiers’
Conference, “Premiers’ Commitment to their Citizens,” News
Release, Winnipeg, 11 August 2000 (also available at http://www.scics.gc.ca/cinfo00/850080017_e.html).
Barbara Ouellet (4:41).
David Feeny, The Generation,
Evaluation and Application of Health Care Technologies in Canada.
Brief to the Committee, 29 March 2001, p. 5.
Experts often include the innovative ways to finance, organize and provide
health care under the category of disembodied health care technology.
 Dr. John Radomsky, CAR
 David Feeny, Brief to the
Committee, pp. 5-6.
British Columbia Medical Association, Turning
the Tide – Saving Medicare for Canadians, Part I of II: Laying the
Foundation for Sustaining Medicare, Background Paper, July 2000, pp. 31-34.
Konrad Fassbender and Melinda Connolly, An
Empirical Review of Health Expenditures and Technology – Part 2 of 5:
Literature Review, Institute
of Health Economics, University of Alberta, Working Paper Series no. 00-08,
Dr. Paul R. Gully, Infectious disease trends in Canada, Brief to the
Committee, 4 April 2001, p. 2.
Dr. Paul Gully, Brief, p. 5.
Dr. Paul Gully (6:10-11).
Dr. Christina Mills, Chronic Diseases and Injuries in Canada, Brief
to the Committee, 4 April 2001, p. 4.
Dr. David MacLean, Addressing the Burden of Chronic Disease in Canada,
Brief to the Committee, 3 April 2001, p. 1.
Dr. David MacLean (6:14).
Dr. David MacLean, Brief to the Committee, p. 4.
Dr. David MacLean (6:16).
Federal/Provincial/Territorial Advisory Committee on Population Health, Toward
a Healthy Future – Second Report on the Health of Canadians, Ottawa,
1999, p. 19.
Dr. Christina Mills, Brief to the Committee, p. 10.
Kimberly McEwan and Elliot Goldner, Accountability and Performance
Indicators for Mental Health Services and Supports: A Resource Kit,
prepared for the Federal/Provincial/Territorial Advisory Network on Mental
Health, Ottawa, Health Canada, 2000, p. 30.
Dr. David MacLean, Brief to the Committee, p. 3.
Dr. Christina Mills (6:6 and 6:8).
Dr. Christina Mills (6:7).
Dr. David MacLean, Dalhousie University (6:25).
Christina Mills (6:9).
Paul Gully (6:26).
The demographic information comes from the following three publications:
Indian and Northern Affairs Canada and Canadian Polar Commission, Estimates
Part III, 2000-2001; Statistics Canada, 1996 Census: Aboriginal Data;
Health Canada, A Second Diagnostic on
the Health of First Nations and Inuit People in Canada, November, 1999.
Indian and Northern Affairs Canada and Canadian Polar Commission, Estimates
2000-2001, Part III, Report on Plans and Priorities, p. 4.
The information relating to the socioeconomic conditions and the physical
environment comes from the following publications, unless otherwise
indicated. Federal, Provincial and Territorial Advisory Committee on
Population Health, Toward a Healthy
Future, Second Report on the Health of Canadians, 1999, Statistics
Canada, 1966 Census: Aboriginal Data; Royal Commission on Aboriginal
Peoples, Final Report, 1996;
Health Canada, A Second Diagnostic on
the Health of First Nations and Inuit People in Canada, November 1999.
The report also pointed out that these figures likely underestimate the
Aboriginal data because some 44,000 people living on reserves and
settlements were incompletely enumerated in the 1996 census.
A Second Diagnostic on the Health of First Nations and Inuit People in
Canada, November, 1999, p, 14.
Ibid., p. 14-18.
Sources include: Federal/Provincial/Territorial Working Group on Aboriginal
Peoples and HIV/AIDS, Making a Difference, May 1999; Federal,
Provincial and Territorial Advisory Committee on Population Health, Toward
a Healthy Future: Second Report on the Health of Canadians, 1999; Jill
Lava and Michael Clark, Diabetes Among Aboriginal (First nations, Inuit
and Métis) People in Canada: The Evidence, 10 March 2000; First Nations
and Inuit Regional Health Survey National Report 1999; Health Canada, A
Second Diagnostic on the Health of First Nations and Inuit People in Canada,
November, 1999; Assembly of First Nations, Brief to the Committee, 30 May
2001; Inuit Tapirisat of Canada, Evaluation of Models of Health Care
Delivery in Inuit Regions, 2000; Mr. Gerald Morin, President, Métis
National Council, 30 May 2001 (16:29-33).
Making a Difference, Report of the
Federal/Provincial/Territorial Working Group on Aboriginal Peoples and
HIV/AIDS, May 1999.
Health Canada, Brief to the Committee, 30 May 2001; Margaret Horn, National
Indian and Inuit Community Health Representatives Organization, Brief to the
Committee, 30 May 2001.
National Aboriginal Health Organization, Brief to the Committee, 30 May
2001, p. 1.
Inuit Tapirisat of Canada, Evaluation
of Models of Health Care Delivery in Inuit Regions, 2000, p. 10.
Ibid., pp. 9-10.
Ian Potter (16:8-9).
National Aboriginal Health Organization, An Examination of Aboriginal
Health Service Issues and Federal Aboriginal Health Policy, Brief to the
Committee, 30 May 2001, pp. 4-5.
NAHO, Brief to the Committee, 30 May 2001, p. 5. These initiatives include
Aboriginal Diabetes Initiative, Aboriginal Healing Foundation, National
Aboriginal Health Organization, Aboriginal Head Start.
Ibid. pp. 7-8.
Dr. Judith Bartlett (16:58-59).
Mr. Gerald Morin (16:31).
Ibid., p. 9.
NAHO, Brief to the Committee, p. 9.
Ibid., p. 7.
Ron Wakegijig, Brief to the Committee, 30 May 2001, p. 9.
Pauktuutit Inuit Women’s Association of Canada, Presentation to the
Standing Senate Committee on Social Affairs, Science and Technology, May 30,
2001, p. 2.
Elaine Johnson (16:26).
Assembly of First Nations, Brief to the Committee, 30 May, p. 5.
Ibid., p. 8.
Dr. Jeff Reading (16:61-62).
CIHI, Supply, Distribution and Migration of Canadian Physicians, 2000
Report, Executive Summary, 9 August 2001 (available at http://www.cihi.ca).
Dr. John Radomsky (5:7).
Dr. Peter Barrett (13:6).
Dr. Peter Barrett (13:8).
The Association of Canadian Medical Colleges, Canadian Medical Education
Statistics, Vol. 22, 2000, Table 8, p. 11.
Canadian Medical Forum, Task Force on Physician Supply in Canada, 22
November 1999, p. 11.
Dr. Peter Barrett (13:8).
Dr Robert McKendry, Physicians for Ontario: Too Many? Too Few? For 2000
and Beyond, p. vii.
Dr. Thomas Ward (13:37).
Morris L. Barer and Greg L. Stoddart, Toward Integrated Medical Resource
Policies for Canada, Prepared for the F/P/T Conference of Deputy
Ministers of Health, June 1991.
The report stated: “isolated policies on undergraduate medical school
enrolment may do more harm than good if they are not combined with
appropriate companion policies concerning graduates of foreign medical
schools, financing of academic medical centres, residency training, and
quality assurance, to name only a few.” See p. 6.
Dr. Hugh Scully (13:11).
Canadian Medical Forum, Brief to the Committee, 16 May 2001, p. 3.
Dr. Hugh Scully (13:19).
Dr. Hugh Scully (13:14).
Dr Hugh Scully (13:12).
Dr. Hugh Scully (13:17).
Dr. Peter Barrett (13:9).
Dr. Thomas Ward (13:36-37).
Dr. Peter Barrett (13:41).
Dr. Peter Barrett (13:7).
Dr. Hugh Scully (13:12).
Dr. Hugh Scully (13:40).
Dr. Peter Barrett (13:9).
Dr. Hugh Scully (13:14).
Dr. Peter Barrett (13:17).
Aiken, Linda et. al., “Nurses Reports on Hospital Care in Five
Countries” in Health Affairs, May-June 2001.
Kathleen Connors (13:65).
Canadian Federation of Nurses Unions, Brief to the Committee, 16 May 2001,
Régis Paradis (13:50).
Sandra MacDonald-Remecz (13:63).
Kathleen Connors (13:54).
Sandra MacDonald-Remecz (13:61).
Dussault, Gilles et. al., The Nursing Labour Market in Canada:
Review of the Literature, December 1999, p. 25.
Kathleen Connors (13:55).
Canadian Nurses Association, Brief to the Committee, 16 May 2001, p.4.
Linda Jones (13:46).
Régis Paradis (13:51).
Régis Paradis (13:65).
Kathleen Connors (13:54).
According to Kathleen Connors , 96 per cent of nurses are women (13:65).
Sandra MacDonald-Remecz (13:61).
Sandra MacDonald Remecz (13:61-62).
Kathleen Connors (13:78).
Sandra MacDonald Remecz (13:61).
Canadian Society for Medical Laboratory Science, Brief to the Committee, 26
April 2001, p. 2.
Peartree Solutions Inc., A Situational Analysis of Human Resource Issues
in the Pharmacy Profession in Canada, Canadian Pharmacists Association,
May 2001 (available at http://www.cdnpharm.ca/).
Dr. Thomas Ward (13:21).
Linda Jones (13:47).
Linda Jones (13:46).
Linda Jones (13:47).
William Tholl (17:18).
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