Essays March 2014
What the Loss of the Health Council of Canada Means for Canadians
On March 31, 2014, the Health Council of Canada will close its doors for good. The council was established in the 2003 health accord, and the 10 years of its existence have been both progressive and tumultuous, not unlike the ups and downs of Canada’s healthcare systems more generally. Whether or not you agree with the decision to close the council, or whether you care, there is a need to assess what will be lost.
The early years of the council were challenged by getting the governance model right. The Romanow Report provided the rationale for establishing a council, but making that vision a reality presented numerous challenges. Trying to critique yet not displease provincial and territorial masters, along with a federal health ministry that footed the bill for the council’s operations, required an ongoing balancing act that on some days did not tip the way we would have liked.
This problem is not unique to the council; there are many other national health agencies, particularly those governed by multiple masters with varying mandates, whose advice is not always in sync with the government agendas of the day. But unlike other agencies, the council represented a new institutional entity that was established primarily to assess and comment publicly on the performance of the provinces and territories in their largest area of responsibility – healthcare – with a view to holding them to account. The council had the further challenge of monitoring the federal government’s performance with respect to its specific obligations under the health accords, including the state of Aboriginal health.
Given these factors, it was not surprising that the first external review of the council revealed that all was not well. Many provinces and territories were not enamoured with our results or, more importantly, the lack of benefit they were deriving from our work. The council was often viewed as a “make-work” irritant for the provinces and territories – always asking for data, information or results, while providing unclear value in return, at least to individual provinces and territories. The review resulted in a renewed five-year mandate (ultimately cut to four years) beginning in 2010, with a new and smaller council, greater provincial/territorial oversight of our annual work plans and an important refinement to our mandate. Now, in addition to continuing to monitor and report on progress on the health accord commitments, the council was asked to focus on identifying best practices and health innovations and to help facilitate their spread across the country.
With the renewed mandate endorsed by all participating governments, the council found its legs. Annual progress reports began to provide comprehensive assessments of health system performance across the country. A successful Aboriginal health series that focused on the challenging policy and program areas of maternal and child healthcare, cultural competency and seniors care resonated with Aboriginal communities Canada-wide and received considerable attention from the media and international academic audiences (Ottersen et al. 2014).
At the same time, the council enhanced its work on the Commonwealth Fund’s annual international health policy surveys, contributing to increased sample sizes to ensure that Canada’s performance at both national and interprovincial levels could be compared internationally. These reports also attracted significant media attention and both public and government reaction. In addition, the council released a number of in-depth reports on elements of the health accords that were of interest to the provinces and territories – reports on topics such as primary healthcare, the National Pharmaceuticals Strategy, home care, self-management support, patient engagement, quality improvement, screening and social determinants of health.
And, this past September, the council produced a comprehensive report that examined the performance of Canada’s health system over the past decade and found the results to be less than optimal. While no great surprise to the council, the report received considerable coverage because, as we suspect, most Canadians believe the rhetoric that Canada has one of the best healthcare systems in the world. The evidence shows otherwise.
In addition to these reports, the council established the Health Innovation Portal (www.healthcouncilcanada.ca/innovation) to provide a home for information on innovative practices from across the country. The portal rapidly became a key place to find and share information on innovative healthcare practices, programs, services and policies in Canada; within a year, it had become the top-ranked search result for health innovation on google.ca.
We could continue to describe the work and value of the council, but an independent evaluation in 2013 provided impartial feedback. It concluded that the council was the first place that most health system stakeholders thought of with respect to health system performance and innovative practices in healthcare (KPMG 2013). The council was seen as avoiding regional, sectoral and professional biases, and as being uniquely positioned to speak to and hear from the Canadian public, with the ability to raise public understanding of complex health system issues.
Now the council is gone. With public and private expenditure on healthcare in Canada over the next decade almost certain to exceed the close to $2 trillion spent over the past decade, there is a need for ongoing, consistent, non-partisan and unbiased oversight. Canadians should demand it, regardless of their ideological or political affiliation. Without the council, will another agency or agencies take up the role? Will these agencies have the necessary legitimacy to hold governments to account on their health reform agendas? Can any agency be successful in this position?
Although many have decried the lack of renewal of the health accords as a major blow to healthcare reform in Canada, we are not among them. Reform, in its varied forms, should not require fixed agreements such as accords – ongoing improvement is now a necessary feature of modern healthcare systems. Having said that, many of the problems the accords were designed to fix still need urgent attention, which will take renewed leadership and political will. As part of ongoing health reform efforts, governments and health leaders must be responsive to Canadians’ experiences as healthcare consumers and taxpayers, while helping the public better understand the rationale for the needed reforms. This is a role we played as a trusted source among the many competing voices on healthcare reform in this country. Without the council, the possibility of a future of informed discussion and debate on the necessary reforms is certainly in doubt.
The demise of the council leaves a particularly large gap in the debate about equity in healthcare. There is no cohesive Canadian healthcare system: it is a collection of often significantly different provincial, territorial and even regional systems. Along with our Saskatchewan, Newfoundland and Labrador and Ontario roots, we have family and friends who live in every region in this country. They do not all have access to the same healthcare. Some of that difference makes sense from a local delivery perspective, but a lot of it does not. With less active federal participation in the health system at the pan-Canadian level, there is greater potential for increasing disparities and inequities in terms of access and quality of care across jurisdictions. As its last piece of advice, our council strongly encouraged the federal government to recommit itself to working with the provinces and territories so that the national interest in healthcare is not lost.
Accountability for healthcare system performance may not be top of mind for all Canadians, but it should be. In the absence of the Health Council of Canada or a clear successor agency, we believe an objective voice for both Canadians and their governments will be lost. This situation needs to be addressed if governments collectively want to ensure public confidence in the measures they are taking to reform the system, and they should welcome the opportunity to be held accountable.
As most ministers of health know all too well, without public confidence in their decisions or those of the health agencies they oversee, public dissent grows, the call for political intervention rises and the wheel keeps turning. The real decisions that need to be made get bypassed, and more resources get committed – though often not based on sound evidence – but the improvements in health outcomes that were promised do not materialize. The result is that the health status of Canadians is not progressing to the levels we expect and deserve. The council has been saying this since its inception.
Will Canadians miss the council? We don’t know. But there should at least be some wonder why governments let it close.
About the AuthorJohn G. Abbott, President and CEO, The Health Council of Canada
Mark J. Dobrow, Director, Analysis and Reporting, The Health Council of Canada
Jack Kitts, President and CEO, The Ottawa Hospital
KPMG. 2013. Evaluation of the Health Council of Canada (HCC), Final Report. Author.
Ottersen, O.P., J. Dasgupta, C. Blouin, P. Buss, V. Chongsuvivatwong, J. Frenk et al. 2014. “The Political Origins of Health Inequity: Prospects for Change.” Lancet 383(9917): 630–67. DOI: 10.1016/S0140-6736(13)62407-1.
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