Health care was broken before COVID-19 arrived

Hey there, time traveller!
This article was published 04/05/2021 (1778 days ago), so information in it may no longer be current.

Since the emergence of COVID-19, Canadians have experienced devastation in our nursing homes, more than 24,000 deaths and a failure to procure an adequate vaccine supply. We have been subjected to waves of restrictions rolling back and forth across the country, tracking the provinces’ futile attempts to negotiate a truce between commerce and nature.

We now face the prospect of prolonged delay to economic recovery, collapse of acute-care capacity in some provinces and many more deaths.

Many other countries have fared better and will likely recover sooner, because their health-care systems were more adaptable, politicians were more knowledgeable and insightful, and public-health leaders were given better support and greater authority.

The failures here were inevitable, and have been at least 30 years in the making. This pandemic has lifted the curtain to expose serious structural, political and cultural problems within our health-care system. We must recognize them, understand their origins and fix them before the next crisis results in even worse social and economic trauma.

Virtually every study over the last 20 years, including those from the World Health Organization (WHO), the Organization for Economic Co-operation and Development (OECD) and the Fraser Institute, has shown that Canadians spend more than most countries on health care and that our system underperforms in terms of access and equity. Only the United States delivers less for more.

Our problems can be summarized into three categories:

1. The limited scope and decentralized nature of our health system.

2. Failure of key public-policy initiatives over the past 30 years that have resulted in among the lowest numbers of per-capita hospital beds and physicians compared to all other affluent countries with universal health care.

3. The gradual isolation of doctors, nurses and other health professionals from policy development and management.

We need to dispel the myth that we have a comprehensive socialized health-care system. We simply do not. The Medical Care Act of 1966 and the Canada Health Act of 1984 established an insurance scheme that guarantees third-party payment for most physician services and lays out conditions for federal-provincial transfer payments.

These conditions are vague and thus rarely enforced. Provinces are obligated to provide and fund acute-care hospitals and little else. Nursing homes and private clinics are excluded. Simply put, physicians and hospital beds are covered but it’s unclear how available they have to be.

Decentralization is the core structural problem. We have 13 independent provincial and territorial systems and two federal systems for First Nations communities and the military.

This structure generates waste through inefficiency, duplication of services and maldistribution of resources, while limiting effective management of supply and equipment costs. Smaller provinces often cannot afford expensive programs, and their citizens have less access to services such as organ transplantation and epilepsy surgery. Larger provinces benefit from efficiencies of scale and spend less per capita than the rest.

Pandemics are national security threats. If our military was to be reconstituted as 13 independent provincial and territorial militias, the absurdity would be obvious.

Decentralization has prevented the development of a deep professional, federal health-care authority with a national perspective and the ability to develop and implement sound, evidence-based policies. When political ideology trumps science and critical thinking, bad decisions usually result.

For example, in 1989 the provincial, territorial and federal deputy health ministers commissioned the Barer Stoddard Report; its recommendations were based on three dubious or false assumptions: that health-care spending was rising uncontrollably, that this spending was a drag on the economy and that doctors were the primary drivers of health-care spending.

The recommendations were embraced by governments and a 15 per cent reduction in medical school enrolment was implemented across the country. Within a decade, critical shortages of physicians emerged and wait times for services became epidemic. We have yet to recover.

A study from the Fraser Institute in 2020 demonstrated that Canada still ranks third-last in per-capita physician supply among the 28 wealthy OECD countries with universal health care.

The subsequent Romanow Report was more enlightened, but implementation of its recommendations at a provincial level was selective and expansion of community health services was largely funded through hospital bed closures. The same Fraser Institute study confirms that we now have the second fewest per-capita acute-care hospital beds and the lowest hospital admission rate among 28 comparison countries.

The result is crowded emergency rooms and admission delays. Cynically, governments respond by pointing out that hospital lengths of stay are longer than in some other countries, implying that our hospitals are inefficient instead of recognizing that Canadians have to be much sicker to qualify for an admission.

Reduced physician and hospital bed numbers have dire consequences for physician workload and ultimately create access issues for patients. Doctors now have remote access to medical information systems. For many, their homes have become offices and, since the pandemic, even clinics, extending work hours over evenings and weekends. Institutions respond by offering stress counselling as they increase service demands.

Physicians in high-performing countries play an integral role in improving and managing services. With no reasonable avenues for structural change and dwindling resources, our physicians generally have less time and interest in these activities than their European and Asian counterparts. Cynicism and mistrust among doctors are becoming pervasive, and our pandemic response has not improved their mood or outlook.

Decentralization, bad policy decisions, poor implementation and the resulting contraction of vital resources are self-inflicted injuries that have left us particularly vulnerable to this pandemic. Further, our government’s failure to invest in biotechnology and pharmaceutical production, despite a robust pool of talent, expertise and resources, has contributed to our poor vaccine-supply situation.

Canadians can deliver quality social programs that dominate on the global stage. Since 2000, the OECD has been testing 15-year-old secondary students in reading, science and mathematics. Canada scores among the top 10 in all three domains and ranks sixth among 79 countries. Further, Canadian results show only a marginal difference in performance between students from rich and poor households. Here, we not only outperform other countries that outspend us; we also rate highly in the areas of access and equity.

I am not advocating that Canada spend more. On the contrary, moving to a more federalized model would reduce waste and overall costs. The road to a more sensible framework could be a complicated political process. The Canadian Constitution assigns jurisdiction of health care to the provinces. However, the federal government determines the qualifying conditions for transfer funding. Therefore, there is potential leverage to set national goals and standards for access and equity.

Provincial governments could be encouraged to collaborate in planning capacity for organ transplantation and other services. Only a federal government can prepare for a pandemic.

There may be concerns that more federal control would lead to neglect of local communities. In the United Kingdom and other comparable countries, there is actually more local community control of health-care spending, but in a more transparent and accountable manner.

The pandemic has laid bare the tragic faults in our patchwork medical system. We must not let this warning go unheeded: Canadians must insist on a national discussion on the future of health care.

Dan Roberts is a Winnipeg physician who served as head of the Winnipeg Regional Health Authority’s medicine program and head of the department of medicine at the University of Manitoba from 2001 to 2016.