If everyone agrees that the lack of doctors is among the causes of the current situation, few people remember how we got there. In 1964 The Royal Commission on Health recommended an increase in the number of places in medical schools, which was implemented with the help of the federal government. The situation had improved up until the early 1990s and the release of the Barer and Soddard’s report, “Towards an integration of medical resources in Canada”. The report contained fifty recommendations including that of a 10% reduction in access to medical schools. Curiously, this recommendation was the only one to be implemented by provincial governments in 1993. For some years, the number of places available has been considerably less than the reduction proposed by the report. (In 1997, the number of places was reduced by 18.5%.)
In 1997 two other phenomena have a direct impact on the supply of physicians: the departure of a significant number of them abroad, particularly to the U.S. and the growth of the Canadian population. Between 1996 and 1998 no fewer than 1,959 physicians left Canada. And while the number of physicians and nurses decreased, the population of Canada did not stop growing. Between 1973 and 1990 the population rose from 22.5 to 27.5 million, an increase of 5 million people.
Rising costs, including those of drugs and equipment, combined with the sharp reductions in federal contributions were added to the multiple causes that undermine the health care system.
Governments, regardless of their political colour, have acted rashly and without vision and knowledge of the global context. On two occasions, in 1987 and 1993, the Conservative government of Brian Mulroney granted the pharmaceutical companies special advantages in exchange for promises of developing the research and development sector in the Montreal area. Far from respecting their promises, the pharmaceutical companies spend more money on marketing and promotion than on research and development. To the price of drugs, one has to add the price of medical equipment which is being continually perfected.
And while all kinds of costs increased, the Liberal government of Jean Chretien dramatically cut transfers to the provinces for health care. The agreement signed in 2004 between the Martin government and the provinces only partially restored the level of federal contributions.
Another phenomenon has had a huge contribution to the insidious deterioration of health care in Canada: the reduction of taxes. In the 90s, governments began to cut taxes for individuals and companies. In 2006, the coming to power of a very conservative government has pushed this trend even further. Provincial governments have followed the same policy. If the benefits of these reductions have been minimal for most citizens, the impact has been significant for the governments that have seen their incomes decline rapidly and significantly. Between 1997 and 2004 tax cuts have deprived governments of about 170 billion dollars. The total revenue for the provincial governments is currently lower by about 35 billion a year. With little understanding of this very complex situation, citizens have continued to ask for more and more services.
The aging population and the need for long-term care add to the other causes already mentioned and have contributed to the current crisis.
Before analysing the internal forces that influence the health care system, one must note briefly the impact of external forces.
For nearly 50 years trade liberalisation has been limited to products. Since January 2000, under the General Agreement on Trade in Services (GATS) services were added to the multilateral trade negotiations. In the long list of services covered by GATS there are health, educational and cultural services as well as engineering, architectural and many others services. In the spirit of the agreement, all these services should be privatized and opened up to foreign competition. These external forces, notably the U.S. health and insurance companies, are pushing very hard for the privatisation of health services in Canada.
The first internal stakeholder consists of Canadian citizens, both payers and beneficiaries of the system. They are unorganized individuals, with divergent interests and most of them are interested in the health care system only when a health problem forces them to use it. They are influenced and even manipulated by the information available in the media. Generally this information is controlled by other stakeholders. Citizens usually have a limited knowledge of the system and know little about the ideological orientation and interests of other stakeholders. Quick to denounce the problem when they are directly affected, most of them believe that the solution is more money injected into the system and this without raising taxes. A small part of them, having the means, become supporters of the privatisation of health care. Very few of them have a realistic idea of the reality of a private health care system.
The second stakeholder consists of the provincial and federal governments. If the governments that implemented the Canada Health Act were made up of visionary politicians with a strong sense of the common good and public interest, the governments in place since the early 90s have been made up of political managers whose only vision has been to ensure, at any cost, victory in the next election. The neoconservative wave that has swept the world after the fall of the Berlin Wall has made governments increasingly dependent on powerful corporate lobbies that have imposed theirs vision and interests. The common good and public interest, up against the interests of multinational corporations whose only goal is to increase profits at any cost, have faded away gradually.
Despite lots of reports, analyses and recommendations to improve the system, governments, stuck between the interests of corporations and public pressure, have left the system to drift. For many years the only solution has been to inject more money into a system in continuous deterioration. At the same time, by cutting taxes, governments have been depriving themselves of huge amounts of revenue. The addition of money to a system that needs structural changes is only postponing the implosion of the system.
Representatives of corporate interests are the third player influencing the health care system. Of course, they are representatives of pharmaceutical, insurance, health care management companies and so on, and they all lobby for the privatisation of the public system. In Canada there are about $150 billion annually that are still under the control of the public system. It is easy to understand why these companies spend huge amounts of money, not only to keep constant pressure on governments, but also to disseminate biased information presenting an apocalyptic vision of the public health care system.
In addition to the lobbies, these companies subsidize many research centers with a neo-conservative orientation that regularly publish reports trying to convince citizens that the public health care system is unsustainable. Without any exaggeration, one can speak of a system for manipulating public opinion and creating an environment of fear and whose final objective is the privatisation of health care.
The unions of the workers in the health field, another important stakeholder, invoke the public interest to extract for their members a large share of the collective wealth that, thanks to tax cuts, is constantly shrinking.
As for the doctors and nurses associations, until recently, they did everything to prevent access to the practice for their colleagues recently immigrated to Canada. For many years the threat of moving abroad, especially to the U.S., has served as an argument to negotiate more money for theirs members in spite of the precarious situation of public finances. As with the unions, the common interest and general welfare disappeared in favour of the private interests of theirs members.
At last, one must mention the role played by the media. In the last twenty years in Canada there has been a very high concentration of both print and electronic media. Canada is the developed country with the largest concentration of media. Due to the lack of resources or ideological orientation, the media have been making the situation even more confusing.
Some myths – Some facts
The current health care system is not viable because of the expenses that are increasing too quickly.
In June 2010, Dr. Robert Evans, a health economist of international reputation, showed that since 1975, expenditures on health insurance, including hospital services and those provided by physicians, have remained stable at 4-5 % of the gross domestic product (GDP). What has increased it was the expenditures for the uninsured components including drugs, dental care and others services not covered. Thus, the cost of drugs has been increasing by 15% per year. Dr Evans noted that expenditures for health insurance now occupy the same share of provincial spending as 20 years ago.
The aging population makes the cost of health care unaffordable.
Same advocates of this myth are already proposing old-age insurance. In reality, the aging population, which is increasing by 0.8 % per year, costs less than the costs driven by the population growth (1%) or inflation (2-2.5%). Speaking of a gray tsunami is only diverting attention from the rapidly rising cost of drugs and equipment.
The privatization of the health care will help solve the problem.
The private system does not form or train physicians or nurses. It recruits among those working in the public sector. In areas where private clinics have already been installed, it was found that the shortage of professionals is worsening, waiting times become longer, costs increase because the public sector must raise wages to retain staff and the dependence on professionals trained outside of Canada is growing. It is essential to highlight that the delivery of these services by the public system does not have as an objective making a profit and that these services are offered at cost.
There are not many for profit private clinics in Canada.
Few people know that despite the Canada Health Act, more and more private clinics are opening in Canada. A recent study counted more than 42 private clinics for magnetic resonance imagery (MRI) and computed tomography (CT), more than 72 surgical clinics and more than 16 medical clinics serving as points of service. Most of these clinics have opened in the last 15 years. Ownership of private clinics changes rapidly. Clinics owned by Canadians are beginning to pass into the hands of U.S. multinationals.
Private clinics are very effective and work well.
In early May 2010, Health Resource Center, a private hospital in Calgary, declared bankruptcy. No need to mention that the debts were picked up by the public system and ultimately by the Alberta taxpayers. In the early 2000s this private hospital was the spearhead of the Ralph Klein government’s strategy to introduce private health care in Alberta. The government had even passed the Health Care Protection Act to provide advantages to this hospital.
What solutions for the future?
First of all, it is difficult to envision viable solutions for health care in Canada without a real public debate on a crucial question: Are health and health care in Canada common goods of public and general interest or simply commodity-services open to competition in order to generate a profit? The solutions depend upon the answer to that question.
Two others conditions are prerequisites for the implementation of real solutions that will sustain the public health system.
The citizens, users/payers, should organise themselves and become directly involved in the development and implementation of solutions. The same citizens should understand that the government is neither rich nor poor, and the money it spends comes from taxpayers’ pockets. Continuing to request services and at the same time asking for more tax reductions is totally nonsensical.
In turn, governments should act in the common good and general interest and stop yielding to the powerful corporate lobbies. Our governments should have the courage to implement the solutions already suggested in the recent years by numerous reports. The report of the Romanow Commission, the Senate’s reports about health care, the reports of the Canadian Medical Association and so on, all of these reports contain proposals for solutions that could be studied and applied for the benefit of all Canadians.
It would take too long to list all of these proposals. Note that just the establishment of a national pharmacare program would save $10.7 billion of the $25 billion currently being spent on drugs.
Improving the quality and the safety of care through the establishment of a smart card containing medical records is another solution that would save a lot of money over time.
The most important is that the governments should have an overview of the system and act in favour of a long-term vision and not only to save same money until the next crisis or until the next election.
It is encouraging to see that lately, more and more of the proposed solutions to maintain the viability of the public health care are coming from within the system. More and more professional practitioners are offering viable solutions, based on their practical experience.
The solutions are there and the governments must have the courage to act now to implement them for the well being of all Canadians, instead of for private corporate interests.