Upload
lars-sharp
View
24
Download
1
Embed Size (px)
DESCRIPTION
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 - PowerPoint PPT Presentation
Citation preview
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
Political Decentralization
Decentralization and Role of Private Sector in Canada
Funding Administration Delivery
Public & Universal (Canada Health Act) hospital, diagnostic and physician services
Public taxation (general revenue funds of governments)
Universal, single-payer provincial systems. Private self-regulating professions under provincial legislative framework
Private professional and for-profit, not-for-profit and public arm’s length facilities and organizations
Mixed goods and services, including most prescription drugs, home care, and long-term care
Public taxation, private (often employment-based) insurance and out-of-pocket payments
Public services that are generally welfare-based and targeted, and private services regulated in the public interest by government
Private professional, private not-for-profit, for-profit, and public arm’s length facilities and organizations
Private goods and services including dental and vision care as well as over-the-counter drugs and alternative medicines and therapies
Private insurance and out-of-pocket payments including full payments, co-payments and deductibles
Private ownership and control; private professions, some self regulation with state regulation of foods, drugs and natural health products
Private providers and private for-profit facilities and organizations
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
BC AB SK MB ON QC
Physicians 199 191 159 180 174 215
Nurses 773 909 1063 1089 807 924
9
Family Medicine-Specialist and Nurse-Physician Ratios, 2006
BC AB SK MB ON QC
Family Physician to Specialist ratio
1.21 1.18 1.30 1.07 0.93 1.03
Nurse to Physician ratio
3.88 4.76 6.69 6.05 4.64 4.30
10
Inpatient Hospitalization Rates (per 100,000 people, age-standardized)
BC AB SK MB ON QC
1995-1996
10,579 11,229 14,526 11,504 10,216 10,386
2004-2005
7,870 9,467 11,828 9,664 7,665 8,202
11
Average Length of Hospital Stay
BC AB SK MB ON QC
1995-1996
6.4 5.8 6.8 9.3 6.6 9.0
2004-2005
7.1 6.9 6.0 9.9 6.4 8.6
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
Province Population (thousands)
Percentage English-Speaking (%)
Percentage French-Speaking
Mother tongue
Primary in home
Mother tongue
Primary in home
Ontario 12,160 69.1 81.7 4.2 2.5
Quebec 7,546 8.2 10.6 79.6 81.8
New Brunswick
730 64.7 69.0 32.7 29.7
CANADA 31,613 57.8 66.7 22.1 21.4
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