A call for action from the National Forum on Health
Mamoru Watanabe, MD, PhD
CMAJ 1997;156:9991000
[ résumé ]
Dr. Watanabe is Professor in the Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alta., and is a member of the National Forum on Health.
Reprint requests to: Dr. Mamoru Watanabe, Department of Medicine, University of Calgary, 3330 Hospital Dr. NW, Calgary AB T2N 4N1; fax 403 283-8878; watanabe@med.ucalgary.ca
© 1997 Canadian Medical Association (text and abstract/résumé)
Abstract
The author outlines the final conclusions and recommendations of the National Forum on Health. The forum believes that although the preservation of our health care system is essential, change is desirable and necessary. Viewing health and health care issues from the broad perspective of the determinants of health, the forum has identified priorities for action. These include addressing the needs of children and families, recognizing and supporting the role of communities, promoting research and the development of information systems, and addressing the socioeconomic determinants of health. Scientific evidence and societal values must be the foundation for building a more effective, efficient, equitable and compassionate health care system.
Résumé
L'auteur décrit les conclusions finales et les recommandations du Forum national sur la santé. Le Forum est d'avis que même s'il est essentiel de préserver notre système de soins de santé, des changements sont souhaitables et s'imposent. Abordant les enjeux de la santé et des soins de santé dans l'optique générale des facteurs déterminants de la santé, le Forum a déterminé des interventions prioritaires. Il faut notamment répondre aux besoins des enfants et des familles, reconnaître et appuyer le rôle de la communauté, promouvoir la recherche et la mise au point d'un système d'information et analyser les déterminants socio-économiques de la santé. Les données probantes scientifiques et les valeurs de la société peuvent être les assises d'un système de soins de santé plus efficace, efficient, équitable et compatissant.
After 2 years of discussions and consultations, the National Forum on Health has released its final report, Canada Health Action: Building on the Legacy, together with companion documents from 4 working groups on values, balance, evidence and determinants of health, and 3 special reports on women's health, health issues affecting aboriginal people, and pharmaceuticals. In conjunction with other publications and discussion papers released during the 2-year period, these final reports are intended to inform Canadians about how the forum and its advisers view the future of health and health care in this country.
From the beginning, the forum elected to address health from the broad perspective of the determinants of health. The forum devoted a great deal of attention to the health care system not only because it is one of the determinants, but also because Canadians take great pride in their premier social program and are deeply concerned about its survival. The key recommendations made in the forum's final report reflect this pride and concern.
The forum believes that Canada's health care system is fundamentally sound. First-dollar coverage for "medically necessary" services financed through general taxation ensures that Canadians will receive medical attention when they need it, and a single-payer system reduces administrative costs and promotes cost reduction rather than cost shifting. The current level of combined public and private spending on health care -- just under 10% of the gross domestic product -- is sufficient to support access to medically necessary services. However, the system can be improved, and resources can be used more effectively and efficiently. Medicare must be preserved. The key features that must be protected are public funding for medically necessary services, the single-payer model, the 5 principles of the Canada Health Act and a strong partnership between the federal government and the provinces and territories.
Many of the health reform initiatives advocated by a series of provincial royal commissions and task forces during the 1980s were centred on the notion that the system as a whole was fundamentally sound and adequately financed but could be improved. There is, however, a limit to our ability to cope with change. To maintain the confidence of health care providers and the public in the system, the forum advocates careful pacing of change. The bottom line, however, is that change is desirable and necessary.
Preserving our health care system means adapting to new realities and doing things differently. We must complete the job of building medicare. We must expand publicly funded services to include all medically necessary services (in the first instance, home care and drugs), reform primary care funding, organization and delivery, and coordinate care across various settings ranging from institutional to community-based care. The evidence suggests that increasing the scope of public expenditure may be the key to reducing total costs.
A true commitment to improving the health of Canadians demands more than a reorganization of the health care system; it requires us to address factors outside the health care system that affect the health of the population. Recognizing this fact does nothing to diminish the importance of ensuring that people who are ill have access to care. Indeed, the forum believes that thoughtful and visionary discourse about the large picture of health will be unproductive if Canadians perceive it as a smokescreen intended to conceal an attack on access to health care services.
The forum believes that the social and economic determinants of health merit particular attention. This does not minimize the importance of promoting healthy lifestyles or the role of other nonmedical determinants of health, such as the physical environment and genetics. The goal is to raise awareness of the far-reaching implications of social and economic factors and to propose specific actions to improve the health status of Canadians.
Healthy brain development affects health and the capacity to participate fully as a citizen and productive member of society later in life. The period from birth to age 6 is critical because this is when the brain develops. The environment in which children are raised affects the number of brain cells and connections, which in turn influence competence and coping skills. Research tells us that a sense of being in control is intrinsic to good health.
Deprivation during early childhood can impair brain development and permanently hinder the development of cognition and speech. This damage can only be partly offset by interventions in later life.
The forum is concerned about the impact of poverty, unemployment and cuts in social supports on health and has made recommendations to address these issues. Investing in Canada's children through a broad and integrated strategy involving programs and income support, recognizing and supporting the role of communities in building social capital and enhancing health, and recognizing that improving the health of the population depends, above all, on achieving the lowest possible rates of unemployment are high priorities.
The ultimate goal of everything we do in the health sector is to improve the health status and quality of life of populations and individuals. The acid test is whether services, programs and policies improve health beyond what could be achieved with the same resources by different means, or by doing nothing at all. Evidence is key to accountability: the decisions made by health care providers, administrators, policy-makers, patients and the public need to be based on appropriate, balanced and high-quality evidence. The forum understands, of course, that evidence is but one of the many factors that influence decision-making; the values and interests of decision-makers as well as the context in which decisions are made are also important. In addition, the level of available evidence can vary. Although a meta-analysis of randomized controlled trials may represent the highest standard, not all studies have been or can be subjected to the same rigorous scrutiny. Valid information can be derived from qualitative research, case studies and expert opinion, for example. Unfortunately, experience, anecdotes, hypotheses and "gut reactions" have sometimes masqueraded as high-quality evidence, and myths and misinformation have often sabotaged the use of high-quality evidence in decision-making.
The forum believes that evidence-based decision-making -- defined as the systematic application of the best available evidence to the evaluation of options and decisions in clinical practice, management and policy-making -- is the foundation for an effective and efficient health care system. To support such a process, it is necessary to identify and remove barriers to evidence-based decision-making and to develop tools, incentives and strategies to promote the uptake and use of evidence. Where sufficient high-quality evidence is lacking, further research should be pursued. In other areas, the synthesis and translation of available information, critical analyses and systematic reviews, the development of practice and management tools, effective mechanisms for the dissemination and uptake of information, and incentives for the appropriate use of evidence are urgently needed.
To support evidence-based decision making, the forum recommends that a national population health data network be established to link provincial and territorial agencies and a national institute for population health. This institute should be founded as soon as possible with a mandate to develop and maintain a standardized set of longitudinal data on health status and health system performance, to advance the population health agenda, and to report publicly on provincial, national and international trends and public policy issues. Existing organizations that perform some of these functions should be reviewed to determine whether they can fulfil this mandate. The forum also recommends the development of a comprehensive research agenda.
The forum believes that the health of Canadians will be best served by attending to the needs of children and families, by enhancing community action and by addressing the social and economic determinants of health. The preservation of our health care system is essential, but change is desirable and necessary. Scientific evidence and societal values must be the foundation for planning the organization and delivery of health care within a more effective, efficient, equitable and compassionate health care system.
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