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CANADIAN HEALTH CARE SYSTEM

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CANADIAN HEALTH CARE SYSTEM R.A. Spasoff Dept of Epidemiology and Community Medicine 1. MAIN COMPONENTS OF HEALTH CARE SYSTEM Health Professionals... – PowerPoint PPT presentation

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Title: CANADIAN HEALTH CARE SYSTEM


1
CANADIAN HEALTH CARE SYSTEM
  • R.A. Spasoff
  • Dept of Epidemiology and Community Medicine

2
1. MAIN COMPONENTS OF HEALTH CARE SYSTEM
  • Health Professionals...
  • Institutions (places with beds)...
  • Community Agencies...
  • Funders (mainly governments)...
  • Industry...
  • Planning/Coordinating agencies...
  • The public...

3
Health Professionals
  • Doctors family physicians, specialists
  • Nurses BScN, RN, RNA
  • Other health professionals dentists,
    physiotherapists, social workers, etc.
  • Chiropractors? Homeopaths? Naturopaths?
    Reflexologists? Home-makers? Where to stop?

4
Supply of Physicians Nurses
(Number /100,000 population, 1998) Canada Ont
ario Quebec Doctors 185 178 211
Generalists 94 85 105
Specialists 91 93
106 Nurses employed in nursing (only 51 are
full-time) Total 750 689
775 Note that these numbers are declining.
5
Supply of Institutions
(Beds/1,000 population, 1996-97) Canada
Ontario Quebec All institutions 11.8 11.4 9.3
Hospitals 5.4 4.7 4.6 Short-term
3.8 2.9 4.3 Rehabilitation
0.1 0.0 0.2 Long-term
1.5 1.8 0.1 Residential 6.4
6.7 4.7 Numbers sharply down.
6
Community Health Agencies
  • Public Health Units...
  • Community Health Centres...
  • Community Care Access Centres (CCAC)...
  • Voluntary/charitable agencies...

7
Public Health Units
  • Responsible for communicable disease control,
    environmental protection, health promotion, etc.
  • Run by local governments (Ontario, 50 provincial
    funding), regional councils (Quebec, 100
    provincial funding)
  • Locally, City of Ottawa Health Department

8
Community Health Centres (CHCs)
  • Organized clinics (six in Ottawa) offering a
    range of health and social services
  • Sponsored by the community and funded by various
    agencies
  • Medical component funded by Ontario Ministry of
    Health, on global budget basis

9
Community Care Access Centres (CCACs)
  • New agencies intended to coordinate long-term
    care, especially for elders
  • Incorporate home care, patient assessment
  • Funded by Ontario Ministry of Health

10
Voluntary/charitable agencies
  • Often disease-oriented
  • Range of functions, e.g., advocacy (Canadian
    Mental Health Association), research funding
    (Arthritis Society), service provision (Meals on
    Wheels)
  • Some derive much of their funding from providing
    services to public agencies on contract (VON)

11
Funders
  • Governments, especially provincial governments
  • Private insurers (for services not covered by
    public plan)
  • Charitable foundations (mainly fund research)
  • Consumers (for services not covered by any plan)

12
Industry
  • Pharmaceutical manufactures
  • Manufacturers of medical devices
  • Insurance (limited see above)
  • Management consultants, sometimes hired to manage
    an institution

13
Planning/Coordinating agencies
  • Ministries of Health, especially provincial
    (health is a provincial responsibility)
  • Local Health Integration Networks
  • Champlain LHIN plans health services for Renfrew,
    Ottawa-Carleton and Eastern Ontario/Seaway Valley
  • Regional Health Boards
  • All of other provinces

14
The public
  • Patients
  • Voters
  • Self-Help groups
  • Patients rights associations
  • Self care and family caregivers
  • Board members

15
Is it well-named?
  • Is it Canadian?
  • Yes, so far, but American hospital and insurance
    corporations are clamouring to get in
  • Is it a health system?
  • Mostly health care, actually illness care (well
    over 90 of all spending is for curative care)
  • Is it a system?
  • More of a network, rather uncoordinated because
    most of its components are privately owned and
    operated

16
Is it public or private?
  • Public payment of private providers. Most
    hospitals are private, not-for-profit
    corporations most doctors are in private
    practice those working in hospitals are not
    employed by the hospital
  • This arrangement is unique to Canada. Cf USA
    (private-private), UK (public-public)

17
Is It Population-Based?
  • Not very hospitals do not have defined catchment
    areas, doctors do not have defined patient
    populations, and population-based components like
    LHINs and PHUs are relatively weak.
  • Canadians have chosen freedom of choice over
    population-based health care planning

18
Can we define its boundary with the social
services system?
  • Not very precisely. Interfaces with social
    services at many places, e.g., community health
    services like home care, seniors housing,
    Childrens Aid Societies
  • We tend to draw the boundary on the basis of
    which government ministry pays for a service (but
    this often differs across jurisdictions)

19
2. FUNDING OF CANADIAN HEALTH CARE SYSTEM
20
Where does the money come from? (1)
21
Where does the money come from? (2)
22
Where does the money come from? (3)
  • Public-private split about 70 from government
    and falling, lowest in ON, AB.
  • Federal-provincial split by 1995, federal
    contributions had fallen to 31 of total public
    spending (22 of total health expenditures), from
    original 50
  • Health care spending accounts for over 30 of
    most provincial government budgets

23
Where does the money go? (1)
  • Hospitals 31.8
  • Other Institutions 9.4
  • Physicians 13.4
  • Other Professionals 11.8
  • Drugs 15.5
  • Other 18.1

24
Where does the money go? (2)
  • Drugs are fastest growing sector (mainly due to
    increased patent protection), while expenditures
    on physicians, hospitals and capital are
    declining (doctors exert their influence on
    health care costs through their clinical
    decisions, not their earnings)
  • Other (1996) payment administration 2.4, public
    health 5.5, health research 1.1

25
How much money? (1)Total Health Expenditures,
Canada, 1975-1999 in billions of dollars
26
How much money? (2)
27
How much money? (3)
  • Average of 2,600 per Canadian per year range
    2,297 (Quebec) to 2,746 (Ontario)
  • Elders (aged 65) account for 39 of health care
    spending, but only 12 of population
  • Variations in health care spending as of Gross
    Domestic Product (GDP) are much affected by
    changes in GDP

28
Is it the right amount of money?
  • Canada is the 10th highest spender in absolute
    terms, and falling
  • We have a relatively young population
  • US spends too much (14 of GDP) UK probably
    spends too little (just under 6 GDP)
  • No one knows what amount is appropriate. Among
    developed nations, there is no correlation
    between amount spent and health status of
    population

29
3. DECISION-MAKING IN CANADIAN HEALTH CARE
30
Who makes the big decisions?
  • Federal government...
  • Provincial Ministries of Health...
  • Regional Health Boards (all provinces except
    Ontario) Local Health Integration Networks
    formerly District Health Councils (Ontario)...
  • Hospital boards...
  • Hospital administrators (presidents)...

31
Role of Federal Government
  • Has the greatest taxing power
  • Its provision of funding allows it to enforce the
    Canada Health Act, despite its lack of
    constitutional authority...
  • Reductions in federal contributions will reduce
    its influence

32
Canada Health Act
  • Provincial plans must meet 5 conditions
  • Universality entire population must be covered
  • Comprehensiveness all medically necessary
    medical and hospital services must be covered
  • Accessibility in practice, no user fees
  • Portability benefits must be portable from
    province to province.
  • Public administration plans must be operated by
    a public (governmental) agency.
  • Mnemonic UnCAPP

33
Role of Provincial Governments
  • The constitution assigns responsibility for
    health (and most other expensive services) mainly
    to the provinces
  • Provinces provide most of the funding for health
    services
  • Therefore, they are the main decision-makers

34
Role of Regional Boards
  • Regional Health Boards (all provinces except
    Ontario) are responsible for planning and
    sometimes for allocating resources to local
    health services
  • District Health Councils (Ontario) were the old
    planning and advisory bodies their mandate was
    unclear and continually changing. They were
    replaced by the Local Health Integration Networks
    in 2006 not yet clear what has changed

35
Role of Hospitals
  • Hospital boards collectively wield much
    influence, partly because their members are often
    selected for their political connections
  • Hospital administrators (presidents) have
    enormous and growing power at the local level

36
Role of the Medical Profession
  • Modest influence at the macro level
    (policy-making) through advisory role, although
    perhaps less than in the past
  • Doctors makes the key decisions in patient care,
    and thus have immense influence on how well the
    system works, at micro level

37
Role of the Public
  • Traditionally, passive consumers
  • Population health requires the system to be
    responsive and accountable to the public
  • Patients rights and other advocacy groups often
    involve both providers and consumers
  • Members of the public dominate advisory councils
    and hospital boards (but are these non-elected
    bodies representative?)

38
4. IS IT A GOOD SYSTEM?
39
What we mean by good?
  • Effective in treating disease?
  • Seems pretty good, but we dont monitor this much
  • Efficient in treating disease?
  • Less good than many other systems
  • Effective in promoting health, preventing
    disease?
  • Only fair, based on surveys and expenditures
  • Accountable to the public?
  • Not very providers and consumers are not clearly
    linked

40
Is it the best in the world?
  • UN report ranks it 30th overall, mainly because
    of of its high cost. This falls to 35th when our
    high income and education levels are considered
    (they think we should do better than we do)
  • France is first overall (and spends 9.8 of its
    GDP on health care). Japan is 10th (7.1), UK
    18th (5.8), US 37th (13.7)

41
Strengths of the System
  • Very well resourced, relative to most countries
  • Minimal financial barriers to access one-tier
    system contributes to equity
  • Probably provides a rather high quality of
    services
  • Our most popular social program, central to our
    Canadian identity

42
Weaknesses of the System
  • Inefficient
  • Fragmented
  • Still rather institutionally dominated
  • Does not emphasize prevention
  • Not very accountable to the public
  • Not very well equipped to address population
    health

43
5. FUTURE DIRECTIONS
  • Institutional down-sizing shift to community
    care
  • Increasing coordination hospital mergers,
    community hospital management boards
  • Primary care reform payment of groups of
    physicians by capitation
  • Integrated Delivery Systems responsible for all
    care required by a defined population
  • Increasing privatization insurance, hospital
    management, perhaps provision of services

44
References
  • Canadian Institute for Health Information, Health
    Care in Canada 2001. (Available, with other
    relevant reports, at www.cihi.ca/)
  • Shah CP. Public Health and Preventive Medicine
    in Canada (4th ed), 1998. Part 3, Canadas Health
    Care System, pp 283-458
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