Terrence Sullivan looks at where the Canadian health system stands in upholding principles of comprehensiveness, portability and accessibility —Report from a presentation at the 2011 conference of the MUHC-ISAI

The Canada Health Act (CHA) is a federal bill that acts as a political guidepost for the way health services are delivered in each province. However, its clout is directly tied to the importance of transfers from federal to provincial governments. In 1996, the federal government squeezed two major transfers, the Canada Assistance Program (CAP) and the Established Programs Financing (EPF) into the Canadian Health and Social Transfer (CHST) and lowered transfers to the provinces substantially. Federal influence on provincial policies consequently decreased. The implementation of the 2004 Health Accord then dramatically increased transfers to try to recover moral ground and included vague arrangements about how the money should be spent. Accessibility was a main component of the 2004 Health Accord (with the Chaoulli ruling hovering in the background) and its net effect was to focus investment of a massive amount of new federal transfer money on reducing wait times in a targeted set of areas. Everybody fell in line and did a reasonably good job of getting this done.

The principle of accessibility has received a great deal of attention since the 2004 Accord, with wait times for a given set of procedures serving as a proxy measure of progress. Yet, there is a long list of other procedures where we have not done very well. The latest Commonwealth Fund survey shows that Canada has the lowest fraction of people in ERs waiting less than 30 minutes and the highest fraction waiting four or more hours. Long waits are also prevalent in primary care and specialty care and many have difficulty reaching a family doctor during regular office hours.

Looking at comprehensiveness, it is obvious that the composition of medically necessary care has been changing and that we have been sleeping while this goes on. The result today is that Canadians have very good coverage for doctor and hospital care and very spotty coverage for pharmaceuticals and community services.

The Canadian healthcare system does not therefore provide comprehensive coverage of medically necessary care. There has never been a standard for drug coverage in Canada, and those of us who have worked in cancer care are at the centre of the cyclone. We have had two failed attempts to mount catastrophic drug programs nationally; we have a national pharmaceutical strategy that can only be described as extremely weak in terms of its total effort and commitment; and we have the initial effort at some harmonization between the provinces. Many of us are now ready to discuss social insurance as a way of picking up some of the coverage that really is not present under the CHA.

Québec has actually gone its own way and mandated obligatory coverage for pharmaceuticals, and is unique in the country in doing that. The time is ripe for some small- and large-scale experiments related to coverage because we are now failing on comprehensiveness.

The issue around portability is not in the basic ability to be reimbursed for care received in another province, but in the variations in care within and between provinces. The Canadian Institute for Health Information presented data recently on two complicated surgical procedures, pancreatectomy and cancer-related esophagectomy, that should only ever be done in centres that run a high volume of activity. In Saskatchewan, only 14% of people operated for esophageal cancer are being treated in a high-volume centre. The Canadian Health Services Research Foundation produced a chart book of quality and performance indicators that shows inter provincial variations and international variations in specific procedures. We are solidly B players now on the global scene.

In conclusion, the principles of the CHA are not very robust today and, as First Ministers discuss the renewal of the Health Accord for 2014, they should be looking at convincing ways to improve accountability for the enormous amounts of money we spend on health care.