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

1. 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

2. 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

4. Political Decentralization

5. Decentralization and Role of Private Sector in Canada

6. 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

7. 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

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

9. Family Medicine-Specialist and Nurse-Physician Ratios, 2006

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

11. Average Length of Hospital Stay

12. 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

13. Status of Two Official Languages, 2006

14. 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

15. 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

16. 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