Health Care in a Highly Decentralized Federation: The Case of Canada

Gregory P. Marchildon, Ph.D.Johnson-Shoyama Graduate School of Public Policy, University of Regina, Canada

Symposium on Decentralization of Health Care: Reform of Belgian Health Care

Sponsored by Flemish Physicians Association: Vlaams Gennesheren Verbond

Brussels, Belgium, 18 October 2008

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Overview of Presentation

• Nature and origins of political and health system decentralization

• Some health service differences among provinces

• Decentralization and language of health care delivery

• SWOT analysis of decentralization

Political Decentralization

Decentralization and Role of Private Sector in Canada

Funding Administration Delivery

Public & Universal (Canada Health Act) hospital, diagnostic and physician services

Public taxation (general revenue funds of governments)

Universal, single-payer provincial systems. Private self-regulating professions under provincial legislative framework

Private professional and for-profit, not-for-profit and public arm’s length facilities and organizations

Mixed goods and services, including most prescription drugs, home care, and long-term care

Public taxation, private (often employment-based) insurance and out-of-pocket payments

Public services that are generally welfare-based and targeted, and private services regulated in the public interest by government

Private professional, private not-for-profit, for-profit, and public arm’s length facilities and organizations

Private goods and services including dental and vision care as well as over-the-counter drugs and alternative medicines and therapies

Private insurance and out-of-pocket payments including full payments, co-payments and deductibles

Private ownership and control; private professions, some self regulation with state regulation of foods, drugs and natural health products

Private providers and private for-profit facilities and organizations

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Public Universal System

• Medicare: universal hospital + medical care services – Narrow (40% of THE) but Deep (no user fees or co-payments)

• Defined as medically necessary or medically required services

• Funded by both orders of government– 75% by provincial taxation – general revenue funds– 25% by federal government – cash transfers to provinces

• Provincial single-payer administrations• National framework of Canada Health Act

– Five funding conditions/principles: universal, portable, public administered, comprehensive, and accessible

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Decentralization of Health Services

• Do differences in health services increase over time within a decentralized system?

• Are differences encouraged by particular forms of decentralized governance, administration or delivery?

• Snapshot of differences in physician and hospital services in 6 more western provinces

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Number of Physicians and Nurses(per 100,000 people), 2006

BC AB SK MB ON QC

Physicians 199 191 159 180 174 215

Nurses 773 909 1063 1089 807 924

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Family Medicine-Specialist and Nurse-Physician Ratios, 2006

BC AB SK MB ON QC

Family Physician to Specialist ratio

1.21 1.18 1.30 1.07 0.93 1.03

Nurse to Physician ratio

3.88 4.76 6.69 6.05 4.64 4.30

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Inpatient Hospitalization Rates (per 100,000 people, age-standardized)

BC AB SK MB ON QC

1995-1996

10,579 11,229 14,526 11,504 10,216 10,386

2004-2005

7,870 9,467 11,828 9,664 7,665 8,202

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Average Length of Hospital Stay

BC AB SK MB ON QC

1995-1996

6.4 5.8 6.8 9.3 6.6 9.0

2004-2005

7.1 6.9 6.0 9.9 6.4 8.6

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Language of Health Care Delivery

• Important factor in access to, and quality of, health care

• Mainly determined by provincial governments– English-speaking (8) – majority with 4.2% or less with French as mother

tongue (and 2.5% using French as primary language at home)– French-speaking (1) – Quebec with 80% having French as mother

tongue and 82% using French as primary language at home – Officially bilingual (1) – New Brunswick – 65% with English and 33%

with French as mother tongue

• But federal government underwrites cost of providing services to linguistic minorities due to policy (and law) of official bilinguilism

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Status of Two Official Languages, 2006

Province Population (thousands)

Percentage English-Speaking (%)

Percentage French-Speaking

Mother tongue

Primary in home

Mother tongue

Primary in home

Ontario 12,160 69.1 81.7 4.2 2.5

Quebec 7,546 8.2 10.6 79.6 81.8

New Brunswick

730 64.7 69.0 32.7 29.7

CANADA 31,613 57.8 66.7 22.1 21.4

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Quebec

• Motivation behind attaining greater autonomy• Control over culture and language• Control over public health care: CLSCs and

regionalization• Montreal and “bilingual” hospitals and institutions

– McGill University: Montreal General; Royal Victoria; Montreal Children’s Hospital; Montreal Neurological Institute; and Montreal Chest Institute

– Jewish General Hospital– Saint Mary’s Hospital– Lakeshore General Hospital

• Alliance Quebec and subsequent action by federal Minister of Health: $30 m investment

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Ontario

• Health Services Restructuring Commission

• Order to close Montford Hospital, Ottawa

• Pressure on Ontario government from civil society as well as other governments

• Court action

• Reversal of decision and re-investment

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ConclusionSWOT Analysis of Decentralization

• Strengths– Freedom and capacity of provinces to innovate and experiment– Intergovernmental collaboration, federal spending power and balance

• Weaknesses– Non-cooperative strategies of blaming and cost-shifting– Difficulty of setting “national” direction

• Opportunities– Replace old system of cost-sharing with more effective federal-

provincial approach

• Threats– Increased non-cooperation and, possibly, secession