Theatre of discontent
Despite extra funding, one of the world's best health-care systems is showing signs of wear and tear
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WINTER rarely comes this early to the balmier bits of Canada, but a chill has already settled over the country's health services. On October 1st, doctors in Newfoundland shut their surgeries, refusing to treat all but emergencies, hospital in-patients and expectant mothers. In Saskatchewan, 2,500 pharmacists, paramedics and ancillary workers have entered the third week of a walkout. In Quebec, meanwhile, general practitioners are fuming at a new provincial law which requires them to provide services at far-flung, understaffed emergency rooms on top of their normal work.
Canadians are both proud of, and chronically anxious about, their health system, known as Medicare. As enshrined in the Canada Health Act it aspires to combine the public spirit and universal coverage of Britain's creaking National Health Service with the quality of America's high-tech medicine. It does this through delicate balances between public and private funding, and provincial and federal power. “Medically necessary” hospital treatment and doctor services are publicly financed, making up 71% of Canada's C$95.1 billion ($64.3 billion) spending on health care in 2000. But other medical goods and services, such as drugs dispensed outside hospitals, are not always covered. Since their cost is rising, there are calls for a national publicly-funded insurance scheme for these expenses.
But the politics of health are complex. Each province has its own definition of “medical need”. It is the provinces, too, that organise and provide health care, raising revenues to pay for it through local taxes, and disbursing money to providers according to local fee scales. The federal government chips in with payments aimed at ensuring that spending per head on health is the same in rich provinces, such as Alberta, as in poor ones like Newfoundland.
To conservative critics, this is a straitjacket that stifles innovation. Alberta, for example, is experimenting with private for-profit provision of publicly-funded services. On October 1st, Action Democratique du Quebec, a rising force in that province's politics, called for greater private involvement in providing and paying for health services, to increase choice. But these are still minority views. Most Canadians would agree with Adrienne Clarkson, the governor general, when she calls Medicare “a practical expression of the values that define us as a country”. Translation: in health care, Canadians do not want to copy the United States.
But paying for health has risen to the top of Canada's political agenda. In both Newfoundland and Saskatchewan, the strikers complain that their wages are lower than those in neighbouring provinces, leading to staff shortages. The provinces blame the federal government in Ottawa. Last week, Canada's 13 provincial premiers began an advertising campaign to publicise their complaint that the federal share of health spending has fallen by almost three-quarters over the past 20 years, to 14% of the total (30% says Ottawa).
Traditionally, the federal government has used its financial leverage to cajole the provinces to apply the principles of the Canada Health Act. “But if the federal government wants to carry a big stick,” says Michael Decter, of the Canadian Institute for Health Information, “it is going to have to write a big cheque as well.”
Recently, Jean Chrétien, the prime minister, has opened the cheque book. Two years ago, on the eve of an election and with the federal finances in good health, he promised to pour an extra C$21 billion into Medicare by 2005. With the provinces chipping in more too, the freeze in health spending of the 1990s has been reversed. Even so, in a speech opening the new session of parliament this week, Mr Chrétien promised there would be yet more money for health in the next budget.
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So far, much of the new money has gone into wage settlements for health workers. Despite this, Canada still lags behind many other industrialised countries in health-care spending per head (see chart), with fewer doctors, nurses and fancy bits of equipment. The result: doctors are stressed, and patients fed up at having to wait weeks for specialist consultations, high-tech scans or elective surgery such as hip replacements.
Once in the system, however, patients seem satisfied with their treatment. According to the first-ever national survey, published on September 30th, almost 85% of Canadians rated their health services as very good or excellent. On some clinical measures, such as deaths from colorectal cancer, Canada scores far better than bigger spenders such as Germany.
Still, more money will do little to ease staff grievances unless management and working practices are reformed, argues Steven Lewis of Access Consulting, a policy consultancy in Saskatoon. Others point out that one cause of staff shortages is the decision taken a decade ago to cut places for training doctors and nurses, based on flawed projections of future demand. This could be made good by delaying retirement and licensing more foreign doctors (many now work as taxi drivers in Montreal or janitors in Toronto). Or the politicians could challenge the doctors to accept more efficient practices, such as better use of nurses. Quebec might come up with more creative ways of getting doctors to its rural areas than its current method of sending bailiffs to force them to go.
Faced with this icefield of vested interests, Mr Chrétien last year deftly shunted the issue of reform to a commission on the future of health care led by Roy Romanow, a former premier of Saskatchewan. Mr Romanow says that his report, due in November, will offer policy prescriptions (complete with cost estimates and timetables for implementation), not just on such matters as how to deal with waiting lists, but on the underlying political options facing Canadians. These include how to balance demands for more consumer choice through health-care privatisation with calls for greater social equity through public financing, and how to reconcile national standards with local needs.
Mr Chrétien has said he will convene a premiers' meeting early next year, to discuss the Romanow proposals. But Canadians should not hold their breath. “Health care is Canada's third rail, the one politicians hate to touch,” Gary Mar, Alberta's health minister, says. A little shock therapy might be just what the doctor ordered.
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