Report 3 - Exploring the Link Between Work-Life Conflict and Demands on Canada's Health Care System

Appendix A - History of Thinking Around Health Care in Canada

This appendix provides a brief overview of the history of health care reform in Canada. This review is not intended to be a comprehensive critique of this issue-such an effort would be beyond the scope of this report. Rather, the objective of this appendix is to provide context for this study and help the reader put the arguments and recommendations advanced into context.

Canadians are consumed with health and health care

Canadians are preoccupied with issues surrounding health and the provision of health care (CIHI, 2003). In the past several decades, there have been numerous task forces and commissions at the federal and provincial levels which have been tasked with diagnosing the nature of the problem and recommending solutions.

CIHI (2003) identifies three waves of reform that have led to the current set of health care initiatives:

• 1970s: Alternative Delivery and Organization Models Emerge: Focus was on the involvement of teams of health care professionals.
• 1980s: Primary Health Care Teams Expand: Focus was on expanded roles for non-physician primary health care professionals. While regionalization began at the end of the decade, provinces still had the main responsibility for fee-for-services funding for physicians.
• 1990s: The Age of Pilot Projects-Testing Change: Focus was on pilot demonstration primary health care projects which explored alternative methods of organization, delivery, governance, funding and/or remuneration.

An excellent summary of what policy makers have learned from these pilots can be found in the CIHI report (2003, pp. 22-23). The section below provides a brief summary of how thinking on health care vis-à-vis health promotion and population health models has evolved in Canada since the 1970s.

The 1970s: Alternative Service Delivery

During the 1970s, Canada pursued an agenda to promote the health of the Canadian population. In 1974, Marc Lalonde (who was the Minister of Health at the time) issued a report entitled A New Perspective on the Health of Canadians. This document espoused the following ideas:

People's health is influenced by a wide range of factors, including "human biology, lifestyle, the organization of health care and the social and physical environments in which people live" (cited in Townson, 1999, p. 1).

"Personal decisions and habits that are bad from a health point of view create self-imposed risks. When those risks result in illness or death, the victim's lifestyle can be said to have contributed to or caused his own illness or death" (cited in Townson, 1999, p. 2).

In other words, while the view espoused in Lalonde's report is in line with the population health model, the policy focus was more along the lines of the health promotion model (i.e. the emphasis was on the individual and the "choices" he or she made with respect to health-engaging in healthy versus unhealthy behaviours-rather than the social environment and its impact on health and the kinds of decisions an individual is able to make).

1980s: Primary Health Care and Regionalization

The provincial reports in the 1980s identified the following major themes: regionalization of health care delivery, an emphasis on wellness, prevention and population health, and the need for health care reform (CIHI, 2003).

In 1986, Jake Epp (who was Minister of Health and Welfare at the time) responded to the World Health Organization's challenge to governments to outline plans for meeting its goal of "Health for All by the Year 2000" by issuing a document entitled Achieving Health for All: A Framework for Health Promotion (Townson, 1999). This document laid what was described as "a new vision of health" and sketched out six strategies (i.e. ensure access to health information, encourage consensus about health ideas, implement research in support of health promotion, foster public participation, advocate a strong role for the health care system and community health services, and coordinate policies between sectors) which would allow Canada to achieve this objective (Townson, 1999). At this time, the focus was one of health promotion rather than population health. Health policy was viewed as "setting the stage for health promotion by making it easier for people to make healthy choices" and the policy focus was on individual responsibility for improved health through the adoption of a healthy lifestyle (i.e. stop smoking, do not drink and drive) (Townson, 1999, p. 2).

Townson (1999) does, however, note that the government was beginning to see in 1986 that such an approach was not entirely realistic. She offers the following quote from Achieving Health for All (p. 3) to support her argument:

"We cannot invite people to assume responsibility for illness and disabilities which are the outcome of wider social and economic circumstances. Such a "blaming the victim" attitude is based on the unrealistic notion that the individual has ultimate and complete control over life and death."

Also in 1986, Canada hosted the First International Conference on Health Promotion in Ottawa and adopted the Ottawa Charter on Health Promotion. This Charter argued that:

"the fundamental conditions and resources for health are peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity. It calls for co-ordinated action to build healthy public policies, create supportive environments, strengthen community action for health, develop personal health skills and reorient health services" (cited in CIHI, 2002, p. 60).

It also called for action to be taken to build healthy public policy, create supportive environments (physical, social, economic, cultural, spiritual) that recognize the rapidly changing nature of society, particularly in the areas of technology and the organization of work (authors' emphasis), strengthen community action, develop personal skills, and reorient health services (CIHI, 2002).

1990s: Testing Change

The 1990s saw a shift, at least on the stated policy front, from the health promotion model to the population health approach. In 1994, Canada signalled its commitment to population health by issuing its report entitled Strategies for Population Health: Investing in the Health of Canadians. In this document, the Canadian Ministers of Health committed to dealing with all major influences on health, including living and working conditions, physical environment, personal health practices, individual capacity and coping skills, and health services (Townson, 1999).

In 1996, the Advisory Committee on Population Health (ACPH) issued a report entitled The Report of the Health of Canadians in which it stated (as cited in Townson, 1999, p. 10):

"Current trends in many of the most powerful factors that make and keep people healthy, such as employment, adequate income and a fair distribution of wealth are cause for concern."

The report also acknowledges (see Townson, 1999, p. 22) that:

"health is greatly affected by things in our social and economic environment such as having an adequate income, physical safety, learning opportunities and meaningful work. Friendship and other support networks in our families, workplaces and communities, and social roles such as the roles of women and men in society also have an important impact.... In fact, evidence suggests that living and working conditions are perhaps the most powerful influences on health."

This report also noted the important link between healthy working conditions and population health.

The 1990s also heralded a period of fiscal restraint where pan-Canadian public sector health care budgets were frozen or reduced. These budget reductions spanned the years 1993 to 1997 (CIHI, 2003). A shortage of money made it difficult (if not impossible) to implement the ideas espoused in the reports noted above.

The New Millennium: Solving the Crisis

In the new millennium, Canadians awoke to the fact that their health care system is in crisis. Symptoms of this crisis include run-away health care costs, long wait times and health human resource issues (e.g. labour force shortages, labour strife, unhealthy work environments). The response to this crisis has been the creation of commissions and the production of government reports. Major provincial reports on health also published in the early part of the 21st century include those offered by Clair in Quebec, Mazankowski in Alberta and Fyke in Saskatchewan (CIHI, 2003). In 2002, two major federal government commissions also published their findings (CIHI, 2003):

• The Report of the Federal Standing Committee on Social Affairs, Science and Technology (i.e. the Kirby Commission), and
• The Commission on the Future of Health Care in Canada (i.e. the Romanow Commission).

Both of these reports called for major reforms to the health care system while at the same time acknowledging how difficult this will be. The Romanow Commission, for example, argued that primary health care reform (CIHI, 2003, p. 23):

"goes against the entrenched practices of the prevailing culture of our health care system and it sometimes runs into powerful interests and long standing privileges."

It is also relevant to note that the Romanow report identifies "the marginal nature of prevention and promotion activities" to be a major obstacle to health care reform (CIHI, 2003).

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