Canadian & Global Health Policy + Advocacy PDF

Canadian & Global Health: Policy + Advocacy Module 1 Week 1 BSCN3604 Adobe Express Beta  ▪ Frankie Burg-Feret ▪ Email: [email protected] ▪ The best way to reach me is...

Canadian & Global Health: Policy + Advocacy Module 1 Week 1 BSCN3604 Adobe Express Beta  ▪ Frankie Burg-Feret ▪ Email: [email protected] ▪ The best way to reach me is through BB messages. I usually respond quickly but if you do Contact Me… not get a response within 48 hours, I may not have received your message so please try the email above. Office & Hours By appointment If you would like to meet to discuss your progress – do not hesitate to reach out to me – we can chat in person, by phone or Teams.  Class Delivery: In-Person Digital Platforms: Bb & Teams Helpful … Helpful ▪ Canadian & Global Health abbreviated as (“CGH”). ▪ Review the Course Description. ▪ Incorporate Academic Integrity to avoid Academic Misconduct (see Academic Regulations). ▪ Consult your BScN Student Handbook 2024 -2025. ▪ Know that our classroom provides an open space for the critical and civil exchange of ideas.  What the Course Considers? Policy & Advocacy are All of us… in Canada & Opening Oneself to a essential components other countries. Broader World View. of global health. Using “RI” to critically New and familiar self-reflect, understand concepts expanded: our ‘privileged nursing Is achieving equity for social justice, fairness, role’ & consider all worldwide possible? respect for human potential consequences dignity, allyship to name of that role. some.  Be Engaged Adobe Express Beta Strategies 1 2 3 for Prepare & Attend Class. Participate, ask In your Presentation Success Review Weekly questions. Groups, work as a team. Objectives Professors have Use effective Read Required Readings expertise in the Communication & Complete any Course classes they teach and Regular check- In Templates or Course are here to help you. times. videos posted on Bb to Collaborate, keep support learning. minutes, maintain Group Contract. Review Course Outline, Critical Path, Weekly Learning Outcomes, Required Readings, Assignments, + New Test Exam & Assignment Policy Information Literacy is IMPORTANT Students in this course need to access and appraise government documents, nursing position statements, news articles, academic articles related to “CGH” issues. Arvind Kang (he/him) Liaison Librarian | Faculty of Media & Creative Arts (North), Faculty of Health Sciences and Wellness [email protected] Contact him via email to book a research appointment.  See Guidelines: COLLABORATIVE WORK o Guiding Principles: If you believe a class member has incorrectly delineated or defined a theoretical concept (idea): provide constructive feedback (referring to the reading and literature) build on peer interpretations apply ideas from the literature Guiding Principles cont’d: Build on the statements and ideas made in class. Remember to be specific by supporting your views with policy and government legislation from course readings and other relevant literature.  Group Presentation – Review of Assignment Documents ▪Students will have the opportunity to choose group on BB ▪Review all Presentation assignment documents carefully (posted on Bb). ▪There is only one grade for the presentation*. That is, a grade for the group. ▪*exception: if there are extenuating circumstances  Group Presentation ▪Week 2 ▪students will assigned Presentation Groups. Read carefully the topic and materials each student group must consider to research and present their issue. ▪See also the Assignment instructions posted on Bb with special attention to due dates and process to ensure your group completes all the required components.  About Dr. Paul Farmer Pai, M. (Oct 21, 2022,06:24pm EDT) ▪ Paul Farmer, inspirational, physician, activist, academic, humanitarian, and teacher died in Rwanda on February 21, 2022. ▪ Colleagues put together the lessons they learned from him. ▪ Take a couple of minutes and review these lessons.  Lessons Learned (Dr. Paul Farmer) ▪ Lesson 1: Every person matters. ▪ Lesson 2: Practice accompaniment (meet persons where they are). ▪ Lesson 3: Approach everyone with a “H of G” (hermeneutic of generosity) (Anne Sosin). That is, interpret the words and actions of others in a favorable light until given reason to do otherwise. Lessons Learned cont’d ▪ Lesson 4: Make equity the core of global health practice. “The idea that some lives matter less is the root of all that is wrong with the world”. ▪ Lesson 5: Resist socialization for scarcity on behalf of others or don’t settle for a lower standard of health (i.e., COVID vaccine availability).  Lessons Learned cont’d ▪ Lesson 6: Tackle structural and social determinants of diseases. “Until we all understand how social pathologies like racism and gender inequity get in the body and how we get them out, we’ll always struggle with health disparities,” ▪ Lesson 7: Engage communities. Community engagement is needed in all corners of the world. ▪ Lesson 8: Irrigate clinical deserts. Irrigating clinical and public health deserts is possible. It is the “price of admission for all who engage in the noble struggle for global health equity”. Lessons Learned cont’d ▪ Lesson 9: Be in it for the long haul. There isLessons a need for Learned cont’d global health to be ‘more than just a hobby. Perhaps commitment – measured in decades is what it will take to repair the world. ▪ Lesson 10: Counter failures of imagination. Paul Farmer stated, “we live in one world, not three (first, second, third), and “reimagining global health” requires resocializing our understanding of it.” Advocacy How will you exercise your advocacy voice? https:// www.youtube.com/ watch?v=sldQDLDpTMs  PAUSE Imagining Exercise: Build our Class's Working Mosaic in CGH. I could imagine ______ if all people had access to health care?  Opinion vs. Fact & Research ▪ Read, research & analyze thoroughly. ▪ Public Opinions are formed based on personal experience, on media reports about health issues or the condition of our health care system in Canada and other countries, which can be accurate, biased, poorly informed or even deliberately misleading. ▪ To prevent distortions of reality: ▪ Know the issue and the academic/researched position of the issue. ▪ Read newspapers, scholarly articles, policy statements and search statistical databases (Stats Canada). ▪ Use simple statistics and avoid percentages (e.g., avoid statements such as 50 % of persons - provide sample size; illustrate statistics with personal stories from literature/media). ▪ See: McCullough, J. (2023). Myths and realities about Canada's healthcare system. [Video. https://www.youtube.com/watch? v=yB5E0bZad4I  ▪ PolicyComponents of are – at a basic level policies Key Components ideas or plans used to make decisions. In theCGH: context ofPolicy health, the &focus would of Global Health be on decisions about how healthcare is Advocacy accessed and delivered. Global health is about equity, reciprocity and bi- Course directional partnerships.. ▪ – CNA defines Advocacy: ▪ Advocacy involves engaging others, exercising your voice and mobilizing evidence to influence policy and practice. It means speaking out against inequity and inequality. It entails participating directly and indirectly in political processes and acknowledging the importance of evidence, power and politics in advancing policy options. ▪ See: https://www.cna-aiic.ca/en/policy-advocacy/ advocacy-priorities Global Health is Local? ▪ How do we respond to this question? ▪ Are we immune to global health issues in Canada? ▪ Do we have growing poverty? ▪ Could our Canadian health care system collapse? ▪ Infectious diseases? Pandemics? ▪ Widening inequities such as gaps in health outcomes among marginalized populations? (neglected conditions) ▪ Food scarcity? ▪ Housing & Education ▪ Dissemination of health information (vaccines) ▪ Climate Change? ACTIVIT Y Why do professional nursing associations ICN matter? CAN CNO How do professional ONA RNAO nursing associations/ Other regulators have an influence on the healthcare system? McCullough, J. (2023). Myths and realities Review of video about Canada's Build. Manage. Grow. | Wix eCommerce (youtube.com) healthcare system. [YouTube] McCullough, J. (2023). Myths and realities about Canada's healthcare system. [YouTube] ▪Overview of Canadian Healthcare System. ▪Also reviews some of the basic information and discusses reforms under consideration in Ontario. Explains reforms and responses to them. Points out difficulties faced by politicians if they try to change our health care. ▪Note: facts and opinions are not always made clear. As you watch the video are there some clues about which statements are factual and which are opinion? For Example: McCullough, J. (2023) cont’d ▪ (0:29) Healthcare isn't just a public policy, it's a symbol a legend a political debate and a cultural identity… [Value words suggest opinions]. ▪ s. 3 Canada Health Act (1984), Canadian Health Care Policy is to "protect, promote and restore the physical and mental well- being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers." ▪ a reform agenda that has (0:52) been characterized by his critics as privatization or Americanization which are two of the scariest charges you can make in Canadian politics. [words that are demeaning or degrading undermine the criticism] McCullough, J. (2023) cont’d In (3:07) practice Canada's national government has a pretty big say in how those plans are run. The federal government provides a quarter of their funding and has also established various national standards that all provincial plans must conform to in order to keep receiving that funding. McCullough, J. (2023) cont’d ▪ This really excellent [value judgment] book on (3:51) Canadian Healthcare chronic condition by Jeffrey Simpson [who is he? Is he neutral?] says that governments fiscal interest in only paying for what is medically necessary has resulted in Canadian public health insurance plans being deep but narrow. The Deep part refers to the fact that the plans offer comprehensive coverage for the most important surgeries, operations and treatments required to save lives…the narrowness of Canadian public health insurance however refers to just how many less pressing Medical Treatments government plans won't cover including Dentistry, eye stuff, mental health, nursing homes prescription drugs… over-the-counter medications. [Is the list accurate? Not really]. McCullough, J. (2023) cont’d ▪ Do Canadians like provincial health care? Study shows no - CTV News ▪ The study, conducted for the Montreal Economic Institute by the survey agency, shows 48 per cent of Canadians are not pleased with the country’s health care system. The poll was published April 6, 2023. ▪ The results were lower among women (43 per cent) and residents of Atlantic Canada (25 per cent), as well as among residents of Saskatchewan and Manitoba (34 per cent). ▪ Ipsos conducted the poll between March 17 and 20, and spoke to 1,164 Canadians aged 18 and older. ▪ Provincial Health Care survey McCullough, J. (2023) cont’d ▪ Rationing (5:48) Now obviously when you give the public unlimited access to a limited resource like Hospital Services there is a persistent danger that there won't be enough for everyone. The only real way to make such a system work is to restrain access to resources in various ways and this brings us to one of the most controversial aspects of the Canadian Healthcare regime: the degree that hospital treatments and procedures are rationed in various ways to ensure they are being distributed to the public in a fair and sustainable manner… McCullough, J. (2023) cont’d ▪ 6:22 Most notorious rationing in the Canadian system are very long wait times for critically important Hospital procedures.[ value statements] ▪ The Fraser Institute (which (6:34) depending on where you stand politically is either a mildly libertarian think tank or a “gang of right-wing activists”) famous for churning out these reports. The Fraser people note in their full (7:17) report “wait times for medically necessary treatment are not benign inconveniences. Wait times can and do have serious consequences such as increased pain, suffering and mental anguish. Sometimes poor medical outcomes transform potentially reversible illnesses or injuries into chronic irreversible conditions or even permanent disabilities”. [Do your research. Check facts vs. opinion. Critically analyze sources]. McCullough, J. (2023) cont’d ▪ Everybody seems to agree that wait times (7:56) are fundamentally a problem of Supply. Canada simply does not have enough hospitals and surgeons able to address the medical needs of its population in a timely fashion. ▪ This all brings us to Doug Ford the (9:29) conservative prime minister of Canada’s largest province Ontario. His government is hoping to (9:40) alleviate some of the pressures on the health care system by expanding the scope of Ontario's public health insurance plan to cover various medically necessary treatments performed at privately run facilities outside Ontario's government-funded hospital system. ▪ [Also see changes to OHIP coverage]: what-ohip-covers McCullough, J. (2023) cont’d ▪ Now (11:03) to understand these reactions which I think are a pretty dishonest characterization of what is actually going on [in the] Canadian middle class imagination America is often seen as the hell to Canada's heaven and one of the ways that Canadians sustain this belief is through a widely held though simplistic and mean-spirited understanding of how health care in the U.S. is imagined to work… I do feel (13:08) comfortable in saying that I don't think most Canadians really understand how the American Health Care system works in any great detail…Do you? McCullough, J. (2023) cont’d ▪ Private health care in Canadian (15:02) culture has become a term synonymous with American style health care which again is imagined to be this uniquely horrible style of healthcare where patients pay out of pocket for medically necessary procedures. ▪ [Ford] had to (16:05) assume that voters would have a hard time grasping the concept that public insurance covering privately administered medical procedures is not the same thing as forcing people to pay for those procedures …Ontario public (16:58) health insurance is simply being expanded to cover procedures done at privately run places what makes all of this even dumber in my opinion is the fact that Canadians should really be able to grasp these concepts by now. ▪ Canadian public health (17:13) insurance plans already cover a lot of privately administered services and procedures. McCullough, J. (2023) cont’d ▪ In Canada by contrast things (17:39) are more of a mix hospitals are often run by the government but most individual Canadian doctors are incorporated as private businesses and a lot of the downtown or strip mall medical clinics you visit for small problems or private businesses too…the most common estimates usually say that about 30 percent of all Health Care spending in Canada is private which is a normal rate for most countries. Most MDs provide care on a fee for service basis billing OHIP. What about Nurse Practitioners? They are mostly salaried. ▪ Criticisms ▪ Private Clinic overcharging ▪ Staff lured away to if private facilities offer a better pay…pulling qualified practitioners away from small towns and Rural communities ▪ private facilities engage in a lot of predatory upselling into buying extra services not covered by their insurance Professional Associations (Nursing Organizations: Provincial/Territory, National, International) Question: Why do Professional Associations in Nursing Matter? ▪Name of Organization: ▪Provincial/National/International, Leadership & Members: ▪Purpose/Focus: ▪Areas of Advocacy & Strategies Used: ▪Other Information:  Professional Associations (PA) ▪PAs have a role in our health system transformation. A recent study looked at PAs strategies involved in the reorganization of health care into Ontario Health Teams. ▪Eight PAs were interviewed about their activities during a time of healthcare change. ▪The study found PAs balance: (1) supporting members (PAs are highly connected to their members and to other stakeholders), (2) bringing forward practical solutions to government that reflect the needs of their members, (3) seeking out and collaborating with other stakeholders to increase their mutual influence, and (4) reflecting on their role. Indar A, Wright J, Nelson M. Exploring how Professional Associations Influence Health System Transformation: The Case of Ontario Health Teams. International Journal of Integrated Care, 2023; 23(2): 19, 1–11. DOI: https://doi. org/10.5334/ijic.7017  PA Roles (Indar A, Wright J, Nelson M.) In our health system: ▪ Influencers ▪ Facilitators ▪ Connectors ▪ Representors ▪ Transformers ▪ Reorients Above is using RI approaches which seeks a deeper understanding when engaging in broad and specific situations.  Nursing is POLITICAL The Registered Nurses Association of Ontario (RNAO), is an advocate for Ontario’s nurses. Membership is voluntary and is not required to hold a permit to practice e.g., student membership. RNAO prepares materials for both provincial and federal elections. Are the policy issues raised by the RNAO in nurses’ interest? Review the RNAO materials to see how they approached the issues of influencing voters?  Nursing is Political? How well do the strategies of Nursing Organizations relate to the tools for appraising health care systems issues (i.e.,CHA principles, nursing scope of practice)? Is there a conflict of interest in Nursing organizations raising health issues?  NURSING ORGANIZATIONS Nursing organizations can have cooperating, competing and conflicting interests. International Council of Nurses (ICN) consists of more than 130 national nurses' associations representing more than 28 million nurses. It serves as a global community supporting and investing in nurses. College of Nurses of Ontario (CNO) is the Ontario regulator and part of the self governance of the nursing profession. Registered Nurses Association of Ontario (RNAO) is an advocacy group funded by nurses. Ontario Nurses’ Association (ONA) is a union that represents nurses. These groups advocate for nurses and generally for improved health care. However, the interests of their stakeholders may be different and conflicting At the same time as being responsible organizations the information they provide is usually supported by evidence and can be helpful in evaluating information that you may read or hear about.  Other Examples of Nursing Organizations https://indigenousnurses.ca/about Association for Nurses of Indigenous ancestry or with a special interest in Indigenous health. The association initially came together to collectively use their skills, education and cultural heritages to address the appalling overall health conditions faced by Indigenous peoples as seen by Indigenous nurses. This association is involved in research and advocacy. https://canadianblacknursesalliance.org/ CBNA is a recently established group that inspires Black nurses to advance Black Nurses to through empowerment, mentorship and advocacy. This group is affiliated with CNA and the Canadian Association of Schools of Nursing (CASN). https://www.fnaq.org/brief-history.html Filipino Nurses of Quebec is a support and advocacy group which has been active in Quebec since 1992. This organization reflects a long history of Filipino involvement in the Quebec health care system. Membership is open to non-Filipinos who support the philosophy of the group. Example: Nursing Organizations: Provincial/ Territory, National, International ▪ Name of Organization: Canadian Nurses Association - National ▪ Leadership: President and 8 member board incl 1 public member ▪ Members: Nurses including unionized and non-unionized nurses, retired nurses, nursing students, and all categories of nurses (registered nurses, nurse practitioners, licensed and registered practical nurses, and registered psychiatric nurses) Act in the public interest for Canadian nursing and nurses, providing national and international leadership in nursing and health ▪ Purpose/Focus: Development of health policy across Canada Advocate for a publicly funded, not-for-profit health system Advance nursing excellence and positive health outcomes Promote profession-led regulation ▪ Areas of Advocacy & Strategies Used: Racism, MAID, Health Human Resources, Aging, mental health, virtual care, COVID, Indigenous health, pharmacare. Development of advocacy materials and research, communication with governments, international representation of Canadian nursing ▪ Other Information: National voice for nurses since 1908. Membership used to be part of registration in many provinces but is now voluntary across the country. BScN 3604 ONA Week 2 Canadian Health Care Structure  Module 2 Week 2 Nurses in our Canadian healthcare system must be able to articulate issues. Many issues in the Canadian context are also recognizable at a global health level. Healthcare issues are complex, as well as interrelated and require comprehensive analysis that can lead to unexpected considerations. For example, issues can be situated historically, culturally, politically, economically and/or socially. Week 2 cont’d Identifies and explores issues significant to health. What do we analyze to articulate & understand the multiple challenges and potential resolutions of a Canadian healthcare issue. Articulating health issues gives them visibility. Nursing is political and requires an advocacy approach.  Healthcare Issues of Concern can be Found … Practice Issues related to the nurse’s practice (nature of nurse’s work, conditions of nurse’s work) Healthcare System Course Focus Issues related to Healthcare system (healthcare reform, health of Canadians) Profession Issues related to the power, knowledge, and societal beliefs about women’s work, nursing research and education (McIntyre & McDonald, 2014, chapter 1) Example of a Canadian Issue Nursing shortages and trends of nurse hiring/staffing patterns towards overtime, casualization, & use of agency nurses (paid more than full-time employed nurses). Viewing this as an issue, the nurse considers: Multiple dimensions (historical, ethical, legal, social, cultural, political, feminist, and/or economic lenses) Possibilities, barriers, and strategies for resolution. Healthcare Example In Ontario, hospitals can hire staff nurses directly. If staff nurses are not available Hospitals can turn to less qualified staff or agencies who can provided nurses on a temporary basis. Here are some comments on this situation from a variety of sources: Registered nurses (RN) and nurse practitioners (NP) are an essential part of Ontario’s health- care system. One that should be: accessible, equitable, person-centred and integrated. And yet, the province has the worst RN-to-population ratio in Canada. Chronic underfunding and understaffing across all health sectors and the relentless replacement of RNs and NPs with less qualified health-care workers is challenging the effectiveness of RNs and NPs and the system as a whole. RNAO https://rnao.ca/policy/issues/nursing-policy …improving wages is among the best ways to recruit and retain desperately needed nurses and begin to fix the nursing shortage. ONA members have been organizing across the province to push for better wages to improve staffing and patient care. ONA https://www.ona.org/news-posts/ 20230720-hospital-central-decision/  Example cont’d The use of private nursing agencies to fill staffing gaps in Ontario hospitals has more than quadrupled since the pandemic began… in 2020-21, hospitals reported spending $38,350,956 on agency nurses. By 2022-23 that cost had exploded to $173,669,808. "The vast expansion of overtime and agency nurse usage – demonstrated by a truly astonishing growth in both – establishes a true recruitment and retention problem," CTV News Health Minister Sylvia Jones insists the hours worked by agency nurses are dropping and represent less than two percent of all hours work in Ontario hospitals. CTV News https://toronto.ctvnews.ca/ontario-spending-on-private-nursing-agencies-has-more-than-quadrupled-since-pandemic-began-1.6492880  Example cont’d Ford’s refusal to [improve nurses pay]… suggests he has an agenda that has nothing to do with good governance. Rather, he seems motivated to crush the nurses, along with all other public sector workers struggling to catch up after three years of being held to a 1 per cent wage cap. Although the cap was struck down by the courts last fall, the Ford government is appealing that decision and fighting to maintain the cap. In addition to trouncing public sector unions, Ford appears keen to undermine public health care, thereby smoothing the way for more privatization. Certainly, he seems fixated on privatization and promoting private business interests. He doesn’t seem to understand that, as premier, his job is to protect the public, which includes shielding our valued public programs from pillaging by private businesses, whose only concern is making a buck.  Example cont’d In the legislature, Ontario Health Minister Sylvia Jones appears unable to coherently defend health care privatization, lapsing into corporate pep-talk that: “Innovation is not a bad word.” Of course, innovation isn’t bad. Indeed, it’s good. What’s bad is the way Jones and the rest of the Ford government use “innovation” as a cover for crushing workers and channelling public funds to private interests. That’s not innovation. It’s a betrayal of their role as public guardians. And, in any reasonable political universe, that would be a scandal. Toronto Star editorial b0b1-96a8883943ee.html https://www.thestar.com/opinion/contributors/truth-about-doug-ford-s-health-care-plan-it-s-far-more-expensive-than-we/article_a778bb5d-dbdb-536d- Historical and Current Legislations Canada Canada’s Healthcare History, Legal Responsibility & Structure Historical Highlights 1867 British North America Act 1867 (renamed Constitution Act in 1982). Outlines which government (Federal or Provincial) in Canada is responsible for health (Provincial). Federal govt. must work with the provinces to deliver health care. 1947 Premier Tommy Douglas of Saskatchewan was the first to introduce a public insurance plan for hospital services. 1948 National Health Grants. Federal government targets money for specific public needs (i.e., hospital construction, professional training for public health). (Storch, 2014; Petrucka, 2019)  Fork in the Road Canadian and American health care followed very similar paths until the 1960’s Doctors favoured government funded health care for much of the time before 1945 so they would be paid After the end of WWII both countries tried to create single payer government funded health insurance Both failed. In the U.S. because of fears of socialism and in Canada because of provinces refusal to accept a federal plan The US has never recovered but Saskatchewan pushed through to break the impasse in Canada (Feldberg, Vipond & Bryant, 2019). Adobe Express Historical Highlights 1957 Hospital Insurance & Diagnostic Services Act (HDSA)-1957 Introduced universal hospitalization coverage for acute care / Federal government shared cost for all services delivered in hospitals. 1961 1962 Saskatchewan extended public Saskatchewan doctors’ strike. health insurance to physician (subsequently, the start of costs outside hospitals. “fee for service”  Historical Highlights cont’d 1966/67 Medical Care Act (1966) Federal government provides cost sharing through grants for approved hospital and physician services Events leading to Medical Care Act of 1966 Saskatchewan was the first province to test the HI&DSA in 1961(despite a physicians strike in 1962, the public insurance plan was implemented on July 1, 1962) By 1971, all provinces had setup programs that complied with the Medical Care Act of 1966/1967 (Petrucka, 2019; Storch, 2014, p. 18)  Historical Highlights cont’d 1984--Canada Health Act (CHA) Delineates five (5) Medicare principles Combines the Hospital Insurance and Diagnostic Services Act (1957) and Medical Care Act (1966/1967) added principle of accessibility (Storch, 2014, p. 18) Includes restrictions to stop extra billing (by health provider) and user fees ( by hospital) , i.e., to ensure accessibility and universality (Storch, 2014, p. 18) Provided revisions that includes Medicare principle of comprehensiveness which allows for multiple points of coverage for care providers other than physicians, (i.e., under previous Acts access was through physician gate keepers only Note: Monique Begin, was the Minister of Health when CHA was enacted & advocated for “Canada’s right to health”  Historical Highlights cont’d 1984 “The Canada Health Act was passed during a period of broad, global rethinking of health care and the determinants of health. The change in name, from Medical Health Act to the Canada Health Act reflected this new approach.” Main reasons for introducing the Canada Health Act at national level: 1. Increases in cost of health care spending 2. Changing patterns of disease (e.g., chronic conditions) 3. Communicable Diseases(e.g., Severe Acute Respiratory Syndrome in 2003 led to need for national strategy) 4. Commitment to alternative forms of service delivery 5. Critique of scientific medicine by consumer rights and activist agenda (Storch, 2014, pp. 21-22) Canada Health Act  Canadian Health Care Systems Canada’s Health Care System is based on 3 Legal Acts Canada Health System Canada Health & British North Canada Health Act, Social Transfer Act, America Act 1867* 1984 1996 *British North America Act (1867) renamed Constitution Act (1982)  Canadian Health Care System Acts What are the main distinctions? British North Canada Health Act, Canada Health & Social America Act 1984 Transfer Act, 1996 (1867)/ Constitution Act (1982) Addresses Specifies standards, Sets the terms and jurisdictional power conditions, terms, and conditions for between provincial values that provinces transferring funds from and federal must meet to receive the federal government governments federal funding to provinces/ territories (e.g., universality, for: accessibility, portability, Health care public administration, and Post-secondary education comprehensiveness) Welfare  Legal Responsibility for Health Care “…Canadian constitution assigns responsibility of health care to the provinces, [therefore] medicare is administered at the provincial [territorial] level”. Federal and provincial governments have their own responsibilities as per British North America Act/ Constitution Act Canada does not have one health care system, instead there are three territorial and ten provincial health systems with common federal guidelines. (Storch, 2014; Petruka, 2019)  FEDERAL PROVINCIAL/TERRITORIAL GOVERNMENT GOVERNMENT (RESPONSIBILITIES ) (RESPONSIBILITIES) Setting and administering Establishment and Structural: national principles for the maintenance of all types of health care system through health services Constitution the Canada Health Act Act Hospitals Delivering health services for Charities certain groups Asylums i.e., aboriginal communities, military, Decides where hospitals and federal inmates, Royal long-term facilities will be Canadian Mounted Police located and how many physicians, nurses, and other Transfers tax money to health care providers will be provinces and territories on needed condition that Canada Health Act principles are followed (Storch, 2014; Petrucka, 2014, p. 19; 2019, p. 22)  Federal government Provincial/Territorial (responsibilities) Government (responsibilities) Taking census Each province and territory: Collecting statistics (birth, Develops and administers marriage, death) their own health care Providing government insurance plan Structural: policies and programs that Stipulates what is covered Constitution promote health and prevent and how much to spend on Act cont’d disease, i.e., health care services Drug approvals ▪ e.g., coverage for drugs, Assessment of homecare, rehabilitation, environmental risks – and long-term care establishing quarantine varies across the regulations and hospitals Canada for quarantine (Felberg , Vipond, & Bryant, 2019, pp. 263, 266, 269-275; Petrucka, 2009, p. 18; 2014, p. 19; 2019, p. 22)  Provincial Control of Health Spending Core services as defined in CHA are covered Non-core services such as dental care, physiotherapy, prescription drugs, glasses, eye care, services for children living with autism and many more are not covered uniformly. Governments change covered services to reduce costs or to improve public health. For example: Ontario has recently changed the rules around eye care Changes for Seniors (aged 65 years or older) Effective September 1, 2023 Annual Eye Exams Currently: One exam every 12 months for all seniors. Change: Seniors with eligible medical conditions affecting their eyes such as macular degeneration, glaucoma or diabetes will continue to receive one exam every 12 months. Seniors without an eligible medical condition will receive one exam every 18 months. Equalization Program 1957 ― Equalization program to address horizontal imbalances among territories and provinces. Enables territorial and provincial governments to provide their residents with reasonably comparable levels of public service at reasonable comparable levels of taxation. Equalization payments are calculated according to a negotiated formula. Equalization payments from the Federal government are unconditional (i.e., provinces are free to spend payments on public services according to their own priorities). Equalization is renewed every five years.  Equalization Program cont’d Not every province and territory is eligible for Federal equalization transfers (i.e. Ontario, Alberta and BC (“Have” provinces) do not qualify for equalization most years because their revenues are above the levels for equalization). All provinces have received money at some point during the program. Quebec has received money every year and Alberta only 8 times. Equalization is guaranteed by the Constitution. There is a separate program for the territories. (CBC, 2019)  Who Pays for Equalization? “Equalization is financed entirely from government of Canada general revenues" raised through federal taxes on all Canadians. In other words, the amounts paid come from Federal revenue and are not tied to taxes or revenue from a specific province. In practice, federal taxes from a few have provinces, with Ontario, Alberta and British Columbia being the top three, pay most of equalization Provinces have proposed reconsideration of the funding formula, but studies have shown that most of the proposed changes would not change the program very much. (Kalagnanam, Kobussen, Loerzel, 2019)  Despite the two primary goals of Canada’s equalization program — providing all Canadians with access to equitable service levels and promoting economic development Accountability — there are absolutely no conditions attached to spending by recipient provinces, or are the program’s outcomes measured. This is because in our federal system, many services like education and health are the exclusive responsibility of the provinces. The federal government has no authority to direct provincial spending in these areas. (Kalagnanam, Kobussen, Loerzel, 2019) Canada Health Act (1984) Universality (Programs be universally available) Important Accessibility Comprehensiveness Provinces /territories (Accessible (In coverage agree to these to all) 5 Principles of services) principles of Canada Health Act Canada Health Act principles are supported by the collective of the Public Portability nursing profession Administration (Portable (Operated on a across non-profit basis) provinces)  Canada Health Act: Five Principles of Medicare 1. Public Administration CANADA HEALTH ACT (1984): PRINCIPLES OF “MEDICARE” Principle/ Criterion/ Condition Definition The provinces health care insurance plan must be administered and operated on a non-profit basis by a public authority that is publicly Public Administration accountable to the provincial government for the funds spent. Provincial [territorial] governments determine the extent and amount of coverage of insured services. Canadian Nurses Association (2000); Health Canada (2002). Petrucka (2019, pp. 20-21); Storch (2014); also see Canada’s health care system from Health Canada web site:  Canada Health Act: Five Principles of Medicare 2. Accessibility CANADA HEALTH ACT (1984): PRINCIPLES OF “MEDICARE” Principle/ Criterion/ Condition Definition The plan must provide for all Canadians[insured residents] to have reasonable access to insured hospital and physician services without barriers, regardless of income, age, health status, gender or geographical area. Accessibility Additional charges to insured patients for insured services are not allowed (i.e., no extra billing/user fees). Health care services must be available on the basis of need. Canadian Nurses Association (2000); Health Canada (2002). (Canadian Nurses’ Association, 2000, p. 1; Petrucka, 2019, p.21) Storch (2014); also see Canada’s health care system from Health Canada web site.  Canada Health Act: Five Principles of Medicare 3. Comprehensiveness CANADA HEALTH ACT (1984): PRINCIPLES OF “MEDICARE” Principle/ Criterion/ Definition Condition The plan must insure all medically necessary hospital and physician services and as the province or territory permits the services of other health care practitioners, i.e., services “for purposes of maintaining health, preventing disease, or diagnosing or treating an Comprehensiveness illness or injury, or disability” must be covered (primary care model of healthcare). Question: Why does service coverage vary across Canada? HINT: See British North America Act /Constitution Act for government responsibilities. Canadian Nurses Association (2000); Health Canada (2002). Petrucka (2019, pp. 20-21); Storch (2014); also see Canada’s health care system from Health Canada web site. NOTE: Similarities B/W Comprehensiveness & Nursing’s Scope of Practice Principle of Comprehensiveness Nursing’s Scope of Practice (Canada Health Act) as stated in the Nursing Act,1991 (required by the Regulated Health Professions Act (RHPA)) Defined as: Defined as: The provincial health insurance programs must “The promotion of health, and insure all medically necessary services, i.e., the assessment of, the provision of care for and services “for purposes of maintaining health, the treatment preventing disease, or diagnosing or of health conditions by supportive, preventi treating an illness or injury, or disability” ve, therapeutic, palliative and rehabilitative must be covered (primary care model of means in order to attain or maintain optimal healthcare) function” (CNA, 2000, p. 1) (CNO, 2020, p. 3)  Canada Health Act: Five Principles of Medicare 4. Universality CANADA HEALTH ACT (1984): PRINCIPLES OF “MEDICARE” Principle/ Criterion/ Condition Definition The plan must entitle 100% of the insured population (i.e., eligible residents) to insured health services on uniform terms and conditions. Universality negates discrimination based on race, gender, income, ethnicity, or religion Universality [health status]. This also means that Canadians do not have to pay an insurance premium in order to be covered through provincial health insurance programs. Canadian Nurses Association (2000); Health Canada (2002). (Canadian Nurses’ Association, 2000, p. 1; Petrucka, 2019, p.21) Storch (2014); also see Canada’s health care system from Health Canada web site.  Canada Health Act: Five Principles of Medicare 5. Portability CANADA HEALTH ACT (1984): PRINCIPLES OF “MEDICARE” Principle/ Criterion/ Condition Definition The plan must ensure that Canadians are insured by their home provincial/ territorial plan when they move to another province or territory. After a waiting period of (no longer than three months) the new province or territory of residence will provide health coverage. Includes personal coverage when an insured Portability person travels within Canada or abroad. There may be some limits on coverage for services provided outside Canada. Prior approval for non - emergency out-of- province services may be required. (Canadian Nurses’ Association, 2000, p. 1; Petrucka, 2019, pp.20-21) Canadian Nurses Association (2000); Health Canada (2002). (Canadian Nurses’ Association, 2000, p. 1; Petrucka, 2019, p.21) Storch (2014); also see Canada’s health care system from Health Canada web site. Health Canada https://www.canada.ca/en/ public-health/services/publications/science- research-data/canada-health-act- infographic.html What does this mean? The division of federal and provincial responsibilities [due to the British North America Act and Constitution Act] has created a permanent tension between the federal government (collects most of taxes) and provincial/territorial governments, which has seen their mandate for provision of health care services growing each year. (Storch, 2014, p.24) Federal-Provincial Health Funding Periodic meetings occur between the federal and provincial levels of government to resolve how much support Ottawa will supply directly for heath. Meetings can be difficult and involve a lot of posturing for political reasons. Have the provinces spent the money paid already to improve healthcare? Is Ottawa paying enough? For example: Ottawa will say funding of $196.1 Billion will be provided over 10 years. Read carefully because it may not be the next 10 years or it may be money that was promised before.  Federal-Provincial Health Funding In Feb 2023, at a first ministers conference the Prime Minister confirmed a package of $196.1 billion over the next 10 years including $46.2 billion of new money Transfers will be through the Canada Health Transfer and direct agreements with provinces and territories Priorities are family health services in rural and remote areas, a resilient and supported health workforce, greater access to mental health and addictions counselling and electronic health records CHA principles, shared data and direct commitments to specific principles underpin the funding agreements to ensure the desired improvements occur. Health Canada (2023) Working together to improve health care for Canadians,  Due to the British North America Act and Constitution Act there are only 3 ways How can the federal the federal government can influence government introduce provinces/territories: “national” health and 1. They can change the constitution for a specific program they wish to introduce social services (very difficult) programs if provinces 2. They can offer cost sharing programs are responsible for like they did in the 1940’s health care? 3. They can set national standards with penalties for lack of adherence to the Canada Health Act (Storch, 2014, p. 24) Public vs Private Healthcare  Canadian health care system combines: Publicly financed care with private service delivery Organization of Financed through provincial Health Care: Is government payer Canada a completely Private service delivery public system? Providers of health care are self employed, and not employees of the state. (Wiktorowicz & Wyndham-West (2019), pp. 288-289) Comparing Financing and Delivery of International Health Care Systems Delivery Financing Public Private Public Britain, Sweden: National Health Service Private Canada, France: Public Germany,* Netherlands, insurance system Switzerland,* U.S.: Private insurance *Mixture of private insurance and government subsidy: Government regulates and subsidizes private mutual aid societies (Wiktorowicz & Wyndham-West, 2019, Table 11.1, p. 289)  In a publicly financed health care system, all citizens contribute to and pay for the system of health insurance through their personal income and other taxes. Important advantages include: Advantages of a Spreads the burden of illness across the publicly financed entire population so that insurance is health care system? affordable to all citizens, even those with greater risk of falling ill (Wiktorowicz & More effective cost control over health Wyndham-West, care services 2019) Universal coverage Less costly Lower stress for patients Can build in preventative care Lower administrative costs Wait Times  Did you know that the public and health care professionals are invited to search results on-line for wait times? WHY? Ontario Wait Allows clients/patients to share the Times results with health care providers; and, to request a referral for a health care option Strategy as with the shortest wait time. Solution to Ministry of Health and Long-term Care Privatization (2020) Retrieved from: https://www.ontario.ca/page/wait-times- ontario Ontario Wait Times Strategy as Solution to Privatization 1. Ontario’s Wait Time Strategy was developed to improve access to five (5) key health services by reducing wait times for : cancer surgery cardiac procedures cataract surgery, hip and knee replacement MRI and CT scans. 2. Ontario Wait Time Strategy has expanded to all surgeries and time spent in Emergency Rooms 3. Ministry of Health and Long-term Care (2020). Ontario wait times. Retrieved from: https://www.ontario.ca/page/wait- times-ontario 4. Canada data from 2022: https://www.cihi.ca/en/explore-wait- times-for-priority-procedures-across-canada Cambie Case Cambie Surgeries Corporation v. British Columbia (Attorney General), 2020 BCSC 1310 Cambie Surgeries Corporation v. British Columbia (Attorney General), 2020 BCSC 1310 In 2016 a group of BC doctors, medical clinics and patients began a lawsuit asking the court to invalidate BC laws prohibiting private health care clinics from charging more than the fees set by BC’s Medical Services Plan (like OHIP). The claim was that the rights of patients under the Charter of Rights and Freedoms to life, liberty and security of the person and to equality before the law were violated by the BC legislation. The doctors included Dr. Day who had been the president of the Canadian Medical Association. He and other doctors and medical clinics had been operating private clinics that were not always legal under the BC laws (or the Canada Health Act) because they extra billed BC residents. Findings about the effect of private care on Medicare Dr. Day and others had operated medical clinics outside the law for more than 20 years. BC had been penalized by reductions in federal transfers for Medicare because it had allowed the operation of these clinics A final decision in the case (880 pages!) has been released after more than 100 trial days over 5 years. Interesting because extensive expert evidence about the effects of private care on the public system was submitted and the trial judge made some important findings of fact Fact Findings (Paragraphs 1-23) 1. The introduction of duplicative private healthcare in British Columbia would increase wait times in the public system. The doctors’ own experts agreed with this finding. 2. Some patients suffering from non-urgent, deteriorating conditions and waiting for elective surgeries do not receive care in a timely manner because of lack of capacity in the public system. 3. Waiting beyond their assigned wait time for their elective surgery increases the risk of deterioration and reduced surgical outcomes. Fact Findings (2) 4. Timely and high-quality care is provided to patients with urgent and emergent conditions where there is risk to life or limb, and there is no evidence of any deaths caused by waiting for care in British Columbia. 5. The introduction of duplicative private healthcare would increase demand for public care, reduce the capacity of the public system to offer medical care, increase the public system’s costs, create perverse incentives for physicians, increase the risk of ethical lapses related to conflicts between the private and public practices of physicians, undermine political support for the public system, and exacerbate inequity in access to medically necessary care.  1. England and New Zealand which have parallel private systems have longer and larger waiting lists than Canada Evidence of 2. Manitoba researchers found that patients whose surgeons only worked in public facilities could expect a issues with median wait of 10 weeks; patients whose surgeons worked in both public and private facilitates could privatization expect a median wait of 26 weeks. of health 3. Parallel private systems may tend to leave expensive cases to the public systems and cherry pick patients who are healthier and younger or who have conditions care, that are easier and cheaper to treat. Cambie et al. 4. Doctors earn more in the private sector, they have what economists call a perverse incentive to keep public waiting lists long, to encourage patients to pay for private care. Consider McCullough’s Week 1 – Ontario Reforms YouTube… Ontario is going ahead with changes to our current system which will allow private clinics to provide services to the public paid for by OHIP. Given the findings in Cambie why would Ontario do that? What would you want to see (e.g., data, policy documents, expert commentary, economic forecast) to satisfy you that the concerns identified in Cambie would not occur in Ontario? “…new clinics must apply for a licence to operate and show detailed staffing plans "to protect the stability of doctors, nurses and other health-care workers at public hospitals" as part of their applications”. CBC Nursing Related Legislation Bill 124 Ontario limited public sector nurses to a 1% per year increase. Courts have ruled that this law is unconstitutional. Ontario has appealed the decision but is settling wage claims with unions. Bill 60 Your Health Act is part of the health care reforms allowing private for profit clinics to provide services under OHIP. MAiD (permitted in the Criminal Code, R.S.C. 1985 c. C–46) medical assistance in dying has been legalized in certain specific circumstances and can be provided by Nurse Practitioners. Bill 9, Nurses Bill of Rights (1999) proposed law which provided assurances to nurses that they would be able to provide appropriate care and could enforce these rights against the govt.  Recent Controversial Legislation Bill 7 More Beds, Better Care Act, 2022. S.O. 2022, c. 16. Allows suitable patients to be transferred from a public hospital to a long-term care home without their consent. Confidential medical information can be shared to achieve these transfers. The LTC homes are selected by the government and they can be required to receive the patient transfer. Patient/families will incur a fee if they refuse to move. Emergencies Act, RSC 1985 c. 22 This act was used during the Pandemic to assist the federal government in dismantling the Jan 2022 truckers’ blockades. Provides authority to the federal government to take extraordinary measures during emergencies (natural, pandemic, war etc.). Cost of that illegal blockage was 3 weeks of harassment for citizens of downtown Ottawa and $3.9 BILLION lost in trade activity, as per Transport Canada (https://www.ctvnews.ca/ politics/winter-freedom-convoy-blockades-cost-billions-to-canada-s-economy-inquiry- hears-1.6156134) Canadian Healthcare System: Right to Health Week 3 OVERVIEW of Module Health reflects factors Social determinants of such as genetics, health ─ our living lifestyle, living conditions within conditions, upbringing society. & more… Social determinants of health include: income and its distribution, housing, food stability, quality of work and the provision of health and social services. OVERVIEW cont’d Governments (Federal, Provincial, Municipal) form public policy. Public policy decisions in both health and non- health related areas can affect the determinants of health. Public policy in non- health related domains often has unexpected health impacts. OVERVIEW cont’d Why do some countries (or provinces, or cities) use public policies that support social determinants of health while others do not? Political, economic and social forces are relevant to the development of policy. Often policies which appear irrelevant to health strongly influence the health and well- being of people. Bryant c. 9. PUBLIC POLICY Definition (Bryant, p. 233). Course of action (or inaction) chosen by public authorities (in Canada elected officials or bureaucrats exercising powers delegated to them by elected officials) to address a problem or set of problems. All policy can have health impacts.  Policy is based on a Will influence quality set of values and of health. PUBLIC beliefs. POLICY cont’d Shaped by politics, Politicians will economics & social compromise their forces (influence the beliefs when they approach to issues or need support from lack of approach). other politicians or the public to stay in power..  CONCERN WITH THE POLICY DECISIONS IMPACT ALL POLICIES MAY SUPPORT HEALTHY HEALTHY HAVE ON HEALTH. CHOICES. PUBLIC POLICY SUPPORT HEALTHY HEALTH SHOULD BE AS ENVIRONMENT. MUCH A CONCERN AS ECONOMICS. POPULATION HEALTH Improving the health status of the population rather than individuals. Reducing health inequalities is a positive goal as it is fair and usually raises the health status of all. Assumes that reducing health inequalities means reducing material & social inequality. Often less expensive to give people what they need than help them later PUBLIC POLICY & HEALTH Public policy can affect health across lifespan: provision of income, employment security, equitable distribution of resources & education/ training opportunities. EXAMINING A COUNTRY’S PUBLIC POLICY Look at: Transfer of resources ($) through benefits/ provision of health & social services/ employment & education resources / family supports. Measure of success ! look at distribution of resources across all citizens. Pandemic pushed public policy to support citizens in new ways.  Economics is the science that studies how consumers, business, government, and other organizations make choices to overcome the ECONOMICS problem of scarcity. Price, Pfoutz & Chang (2001) p. 6.  HEALTH SERVICES IN CANADA Saw a shift in dollars for Healthcare costs ↑ healthcare in 90’s. ($900/person to $2000/ person). Healthcare practices were not influencing health status. SOURCES OF FINANCES PUBLIC – Taxes GOVERNMENT Federal – income tax, hst., duty. Provincial – provincial income tax, hst., land transfer tax. Municipal – property tax, parking fees and fines, vendors permits. OECD What is the OECD?  Organization for Economic Co-operation & Development. Grouping of developed nations (mostly Europe and North America): Provides indicators of government operations. OECD One major indicator is “government transfers” (redistribution of resources as services, subsidies, investments in social infrastructure). Canada Health & Social Transfer Act is used by the federal gov’t to balance out services between prov’s. GROSS DOMESTIC PRODUCT GDP is the total market value of all the goods and services produced in a country in a year. Usually, this number should go up each year. Used as a rough benchmark for the health of the economy and the financial power of the nation. Price, Pfoutz & Chang (2001) p. 11. GOV’T. TRANSFERS Government takes $ generated by economy & distributes to population as gov’t. transfers. Social Expenditures (2016) averaged 21% of GDP (Range between OECD members 17% to 28%). Canada 17.2% US 19%, UK 21.5%, Sweden 27%.  Considers both cash payments and services. Pensions, health expense, support for elderly, family and disability. SOCIAL EXPENDITURE S (OECD) Social spending is not always accepted. Gov’t attitude towards those in need, seniors, children, role of the state may all affect the policy path. OECD POVERTY Rates of poverty (2015) are higher in USA and Canada than in Sweden and Norway. Nordic nations have a strong social commitment and have reduced poverty rates to less than 9.1% In 2015 UK 11.1%, Canada 14.2%, USA 17.8% of the population live in poverty (>51 million Americans).  Common to Canada and USA. Responsibility for well being lies on the individual. RESIDUALIST If the individual is failing his family or community should help him. APPROACH The state is a last resort. Results in higher poverty rates. POVERTY Policies on poverty reduction (how can we reduce rates of RATES poverty) are clear indicators of a progressive state (Bryant). REFLECT Poverty is clearly a determinant of health and poverty reduction will improve health. PROGRESSIV Poverty is defined differently by different countries or E PUBLIC groups. POLICY  IF POVERTY < 50% of Median Income Canada 12.4% UK 11.1 % USA 17.8% Sweden 9.1% Canadian rates for the elderly are lower than for the general population.  2022 OECD DATA Canada Total Social expenditure is 24.9% of GDP. (2016 it was 17.2%) Poverty 7.4 % (2021) nearly half of 2015 rate. Pandemic spending greatly increased social spending and reduced poverty. As spending has slowed, poverty rates have stayed low. https://www.canada.ca/en/employment-social-development/news/2023/05/canadas-poverty-rate-remains-below-pre- pandemic-levels.html https://www.oecd.org/social/expenditure.htm WELFARE STATES AND PUBLIC HEALTH Social democratic (Sweden, Norway) Universal welfare rights and generous benefits Conservative/Christian democratic (Germany, Italy) Generous benefits tied to employment status Liberal (Canada, USA, UK) Modest benefits, means tests and reliance on the market to provide most solutions MEANS TEST An assessment of a person’s means to see if they need a benefit. OSAP used to do this. How much did you earn? Your parents? Your grant or loan would be based on your answers. Often, it is cheaper to pay the benefit and tax people to recover the money from those who make too much. This is done with Old Age Security for example. When you do this the expense of the means test bureaucracy is avoided. PUBLIC POLICY AND HEALTH Infant mortality and life expectancy rates are better in social democratic welfare states than in Conservative or Liberal welfare states. Spending on public health is highest in social democratic welfare states and lowest in Liberal welfare states. The public policies in welfare states affects the health of their populations. (Bryant) FORMATION OF PUBLIC POLICY Public policy is formed by Political philosophy (socialism, liberalism, communism) Economics – What can the state afford to do? Does it have to cut back? Fight the deficit? Can it impose taxes? Society -- what do people want and expect? Do they expect the state to take care of them or do they expect the poor to suffer.  LIBERAL WELFARE STATE Means-tested assistance (low income). Modest universal transfers. Modest social insurance plans Needy and poor are responsible for their condition. Limited welfare and EI because better benefits would lead to dependency.  In Quebec, day care is generally available to all for $7 per day. Federal govt has entered into DAY agreements with each province for $10/day day-care which has being rolled out (Ontario was the last CARE province to sign on). Q. Is low-cost Day Care a social determinant of health? NATIONAL PUBLIC POLICY In each nation social and cultural factors also contribute to the development of public policy. Q. What are some aspects of Canada that might affect the development of public policy.  Multiculturalism. Immigration. ASPECTS Constitutional Monarchy. NDP, Green Party. OF CANADA Peace Order and Good Government (POGG). Acceptance of Medicare.  Canada has reduced its spending on social policy in the last 20 years. “Common sense revolution” (circa PUBLIC Harris years in 1990s) POLICY Reduction in transfer payments from Federal Government to Provinces 2010-20 Downloading from the Provinces to the municipality. 15 Fight the deficit. Q. Ultimately, who does it affect?  PANDEMIC SPENDING Govt always say that they lack the money to raise social spending. Pandemic saw social spending rise to unprecedented levels and financial catastrophe has not occurred. If the political will exists, govt can afford to make greater social transfers. Aquanno SM, Bryant T. Situating the Pandemic: Welfare Capitalism and Canada’s Liberal Regime. International Journal of Health Services. 2021;51(4):509-520. doi:10.1177/0020731420987079 Towards the Future Canada has a weak welfare state: Do you agree? What is your analysis? Towards the Future … What can strengthen the Welfare State Left-leaning political parties like the NDP and the Green Party. U.S. has no left-leaning parties – weakest Welfare State. Proportional representation (PR) in the legislature. Where there is PR left leaning parties can be represented at the table and move the discussion in a progressive direction. PR has been recently rejected in BC and Ont. POLITICS OF POVERTY How societies view the poor also affects social policy. Poor are lazy and have only themselves to blame – welfare supports are low. Society is responsible for those in poverty and has an obligation to ensure a decent standard of living. How the poor are treated affects their health and the demands they put on the healthcare system. LABOUR UNIONS States with strong union movements tend to have more progressive social policies. Bryant questions whether American and Canadian workers have any real understanding of their class interest. Note: The working poor support policies that hurt them electing Doug Ford and Donald Trump. LABOUR UNIONS cont’d Some unions support left leaning parties which lead policy in a progressive direction. Unions can be conservative (right- leaning) forces too.  Social housing has largely ceased to be created. Action is still very slow. SPECIFIC Daycare and child poverty have been on the agenda for decades, and only in the last 5 years has progress been POLICIES IN made. CANADA Feds and province now trying to expeditiously build homes given crises of affordable homes in Ontario SPECIFIC POLICIES IN CANADA Reducing welfare costs has been a target for governments across Canada and welfare is now too low to sustain many people. Approaches to Health Need to look at behaviours to prevent health problems. lifestyle Govt moved to change Behavioral Approach - environment behaviour => fitness, anti- 1970s development. human biology and smoking. organization of health care. Socioenvironmental Recognition that previous Social conditions beyond Approach - 1980s approaches were not individual control are more development applicable to most people. important than personal will.  Factors within the society that determine the health of individuals. “living conditions” are a simple way of understanding the SOCIAL concept. DETERMINANTS How people live and can live has a significant impact on OF HEALTH their health. Not just money, diet, exposure to disease, fitness, cleanliness, mobility.  On the simplest scale, think about socialized medicine. If you have medicine paid for no OHIP matter what your illness or why you have it, with no financial barriers to access, what is your biggest worry about health? Am I going to get better? PRIVATE INSURANCE If you depend on private insurance, as many people do in the US, you have limits on your claims, you have deductibles, you may have to pay up front and wait for the insurer to pay you. What is your biggest concern if you get sick? Can I afford to be sick? What about the money?  In which system would your living condition related to the cost of medical care be better? STRES Stress of getting better? Or S The stress of paying for your illness? SOCIAL DETERMINANTS OF HEALTH (Kushner & Jackson) Culture / Aboriginal Status Health care services Early life Housing Education Income and its distribution Employment and working Social safety net conditions Social exclusion Food security Unemployment and Gender employment security EVIDENCE Any of the social The study of differences in determinants of health has health between groups more impact on health than demonstrates the any lifestyle choice (such as importance of the social dieting, exercise, stopping determinants of health in smoking). overall health.  Health of Canadians has improved dramatically over the past century. SOCIAL 10-15% of the improvement is due to DETERMINANTS advances in medicine and part is OF IMPROVED due to improved behaivour (less HEALTH SINCE smoking, diet, exercise). 1900 The balance is due to changes in the social determinants of health and the improved living conditions experienced by most Canadians. SOCIAL DETERMINATS OF HEALTH INEQUALITIES Health status differences exist among Canadians Basic medical care is provided but access to drugs is subject to income and access to treatment may be subject to provincial rationing schemes What are the reasons for the differences Partly health access issues Not health behaviours INEQUALITIES Cause mostly seems to be tied to differences in living conditions tied to the social determinants of health. Especially Income which affects all others. Income during early childhood, adolescence and adulthood are all independent predictors of who gets and dies from disease.  Heart disease, stroke, There is a direct accident, cancer, correlation between infectious disease and income and ill health. diabetes all kill more of the poor than the rich. POVERTY KILLS True across all age Behaviours largely groups. irrelevant. PUBLIC HEALTH Public health promotes good Should it be trying to improve health behaviours, diet, the social determinants of exercise, smoking cessation, health instead? safe sex E.g., is it cheaper to treat In a time of tight budgets, and people who have diabetes or rising health care costs can to pay higher welfare we afford not to treat the amounts so that people can social determinants of health? buy themselves better food and not get diabetes  SOCIAL DETERMINANTS OF HEALTH DIFFERENCES B/W NATIONS Nations who reduce unemployment, reduce income and wealth inequality and try to improve the SDH have healthier people Nations that do not do this have sicker populations and higher health costs Canada is better than the US but worse than many Euro states (Raphael, D. Staying Alive) POLITICAL ECONOMY PERSPECTIVES Political economy can explore the interrelationships between economic and political choices and health Economic choices have political consequences E.g. if you pay for prescriptions where does the money come from? Taxes? Sales tax? Income Tax? Capital Tax? Does it matter which pocket it comes from? POWER RELATIONSHIPS Power relationships between groups affect public policy and health. Race, gender and class may all be reflections of power relationships. Unions and left-wing parties reduce the possible extremes of power relationships. Gov’t Ideology & Public Policy Neo-liberalism leads to a smaller social safety net. Policies such as tax reduction tend to make the rich richer and the poor poorer. Neo-liberalism is negative influence on health and the social determinants of health. GLOBALIZATION Corporations not limited by national borders. Don’t like the taxes here, go to low tax area. Makes raising taxes harder. If corporations do not have to participate in strong welfare states, there is a risk that the progressive welfare states will have to change.  HUMAN RIGHTS PERSPECTIVE Canada has signed international agreements that if followed would require governments in Canada to provide broader support for social policy. These international treaty obligations could widen the social safety net. However, the problem often is that the federal gov’t has signed the treaties, but the provinces have exclusive jurisdiction in the subject matter of the treaty. SOCIAL JUSTICE Social justice requires that access to health be provided universally and equally. Neo-liberalism in public policy can undermine social justice.  TYPES OF Liberal – really means WELFARE STATE conservative, small govt. reliance on the market (US, UK, Canada). Social Democratic – high union density and social democratic parties in power (like NDP) universal health care, poverty reduction, generous EI (Sweden, Denmark). Christian Democratic – social welfare based in religious principles, emphasis on the family (Germany, Italy). States can shift over time. The Canadian Perspective of Welfare States  Public Policy choices affect the health of our society. If we provide fewer social supports, then the overall CONSEQU- health of our society as ENCES measured by infant mortality and life expectancy will be poorer. We need to keep the health effects of our public policy decisions in mind.  HEALTH IS A POLITICAL CHOICE WHO Chief, T. Ghebreyesus ─ Shift from individual disease programs to “integrated and people-centred health systems. Universal Health Coverage is the way forward. Access to health services (currently less than 50%). With financial protection (100 million people a year are pushed into extreme poverty by the cost of care). Countries must judge what they can afford and fund health through home grown taxes on tobacco and sugary drinks.  Equally for all (reduces poverty, decreases health costs, extends care to women/groups who HEALTH IS A are often left out, can be an engine of POLITICAL sustainable CHOICE development). WHO Chief looks to G20 and G7 to lead. (Like OECD). Are they the best?  ALLYSHIP The nursing profession can confront, challenge, and change inequities. Improving population health requires addressing those who are least well served. When care is more equitable, just and fair, all members of society benefit. Nurses and Nurse Practitioners of BC  ALLYSHIP FOR NURSES NNPBC has a policy on Allyship defining the term and discussing the BC context. By virtue of their professional status, nurses and nurse practitioners are in a position of privilege in our society and therefore all of us, both Indigenous and non-Indigenous, have an important opportunity to contribute to strategies that reduce the inherent oppression that remains a pervasive social determinant of health for so many.  …allyship is an active, consistent, and arduous practice of unlearning and re-evaluating, in which a ALLYSHIP IS person in a position of HARD privilege and power seeks to operate in solidarity with people and groups marginalized by systems, structures, policies and practices. CONTINUOUS COMMITMENT Allyship is a continuous commitment to ‘unlearning and re-evaluating’ traditional systems whereby persons in positions of privilege, including nurses and other health professionals, seek to support and operate in solidarity with groups or communities disadvantaged by the ways systems and organizations are structured, and by accompanying policies and practices. PHARMACARE Canada does not have a national program to provide drugs to patients for free or on a reduced cost basis. Each province and territory sets their own rules. Children and seniors are often part of a protected group. Costs can be astronomical for patients without access to private drug coverage. Lexchin J. (2017).  PROVINCIAL PHARMACARE Most provinces have supports for low-income patients or in the case of catastrophic drug costs. Some also have a provincial reduced cost plan for uninsured persons. Ontario’s Trillium Drug Program is available if more than 4% of your income has been paid for medication, not all drugs are covered and there are some deductibles. RNAO and Edmonds.  RNAO has supported Pharmacare without means testing for many PHARMACARE years Canada only country with universal ADVOCACY medical care without a universal drug plan RNAO PHARMACARE ADVOCACY Drug prices are rising, and Canada pays more than most other countries. Ont Govt already pays 42% of medication costs for children, seniors and the poor. 10% of patients do not take medication due to cost leading to worse health outcomes and increased expense. Savings of a national system could be more than 40% of the current expense (reduced admin cost, better price negotiation, evidence-based prescribing, better health outcomes. PHARMA INDUSTRY POLICY Federal Govt regulates the pharmaceutical industry. Pharma R & D is very expensive and, in an effort, to control costs govt has partly compromised its independence. Is Health Canada too invested in its relationships with Pharma to serve the role of watchdog? Lexchin J. (2017). THE RELATIONSHIP Pharma is about making money and developing new and useful drugs. Govt reviews and decides if new drugs or new applications for old drugs are acceptable. Pharma is a producer of wealth in the economy and Govt benefits. Lexchin J. (2017) and Edmonds et al NEO-LIBERALISM IN PHARMA Neo-liberalism supports smaller government and leaving the market/ industry to police their own activities. Govt deferred to industry in the areas of drug licencing and post marketing surveillance. Industry fees now fund govt drug approval process Industry can punish the government agency by withholding fees for delays in processing applications Lexchin J. (2017).  DELAY Patents protect the right to make and sell a drug. Patents expire and must be filed before a drug is approved. Delays in drug approvals can cost millions. Currently, approval process is faster with less evidence and often more post approval safety concerns. Lexchin J. (2017). PATENT PROTECTION Patent exclusivity period was extended in 2011. Period of exclusivity from approval to patent expiry averages 11 years. More time benefits industry and costs Canadians more. Canada used to licence generic drugs more quickly. Generic licencing was ended, and costs soared. R & D costs are not factored into price, drug prices are what people will pay. Lexchin J. Time to Marketing of Generic Drugs After Patent Expiration in Canada. JAMA Netw Open. 2021;4(3):e211143. doi:10.1001/jamanetworkopen.2021.1143 INNOVATION Most new drugs approved do not represent better drugs. Between 1997 and 2012 less than 10% of new drugs were significant therapeutic advances. Current system is flawed and costly. Alternatives that protect the value of R & D but avoid the built-in costs of patents are needed. Govt needs to be independent of industry. RIGHT TO HEALTH While a right to health is not expressly enumerated in the Canadian Constitution, diverse fundamental rights of the Canadian Charter of Rights and Freedoms have been significant drivers of access to medically necessary services and a protectorate of health-related values. Jones 2022 p. 1 Global Health Module 2 –Week 4 Reflection The Invisible Knapsack See attached file for self-reflection (29 statements) How many statements apply to you?  https://youtu.be/j2_iukzpHDA?si =gxtQy7ulUDYHBo7b By: Dr. Madhukar Pai A preview of Week 6  Understanding Global Health Global health is a complex and multidimensional field that requires a comprehensive approach. Perspectives on Global Health Global health can be viewed from various perspectives, including technological, economic, sociological, bioethical, and existential, each offering unique insights into the challenges and opportunities in global health. Challenges in Global Health Challenges such as drug-resistant tuberculosis, water scarcity, and the medicalization and monetization of health present significant obstacles to achieving global health equity and well-being. Ethical Considerations Ethical considerations are crucial in addressing global health issues, including the need for social justice, prioritization of resources, and the moral appraisal of actions affecting individuals and communities. Moving Forward Moving forward, a comprehensive philosophy of medicine and health care, grounded in social justice, ethical considerations, and a multidimensional approach, is essential for addressing the complex challenges of global health. Global Health and Global Health Ethics (chapter 1) What is global health? a new “in vogue” term for what was previously called international health or whether it is truly a recognition of what global health means in a post-Westphalian world in which diseases know no boundaries Who are the global health actors? Academics? Wealthy countries? Lower-resourced communities? those whose lives and health are adversely affected by unspeakable injustices driven by now recognized seriously flawed economic policies that have sustained and intensified poverty and miserable living conditions for so many? Benataur & Upshur Global Health and Global Health Ethics (chapter 1) Definition: Global health goes beyond international health to include acknowledgment of the lack of geographic or social barriers to the spread of infectious diseases, and indeed the interconnectedness of all people and all life on a threatened planet. Global health is the science and art of preventing disease, prolonging life and promoting physical and mental health through organized global efforts for the maintenance of a safe environment, the control of communicable disease, the education of individuals and whole populations in principles of personal hygiene and safe living habits, the organization of health care services for the early diagnosis, prevention and treatment of disease, and attention to the societal, cultural and economic determinants of health that could ensure a standard of living and education for all that is adequate for the achievement and maintenance of good health. Benataur & Upshur Global Health and Global Health Ethics (chapter 1) GH connected to social and economic forces 5 metaphors can be applied to Global Health (GH) GH as foreign policy GH as security GH as charity GH as investment GH as public health Benataur & Upshur State of health globally Despite advances in medicine and global economy, widening disparity Almost 50% of people in the world lack access to basic health care, living in poverty, environmental degradation ~1/3 (18 MILLION/year) die d/t poverty-related causes 50% of these deaths are in children < 5 yrs People of colour, females, the very young OVER-represented among global poor Life expectancy disparity (~ 40 yrs in Sierra Leone, Angola, Afghanistan vs. > 80 yrs in Japan, Switzerland, Australia) Africa most severely afflicted region/continent > 800, 000 deaths globally and 91% of these are in Africa 85% of African deaths in kids < 5 years ~33 million live with HIV globally; of these, 22 million are in Africa 99% of maternal deaths in developing countries Benataur & Upshur  Medicalization and Monetization of Health Variety of access (ie: dialysis) not equitable Situated within a technologically, profitability, medically needed framework Extrapolate this to GH Ie: drug access that is funded by big pharma versus inadequate attention to food, housing, clan water Why is health dependent only on technology or pharmaceutical advancements? When it does not address clean water, food security, food sovereignty, sanitary measures, gender discrimination and implications for health, universal access to basic health care (essential for improved population health) …this is the medicalization of health, of global health, Benataur & Upshur How should we think about global health? The dominant value system is $$$ Within months $17 trillion can be given to uphold bands and financial services compared to $750 billion for millennium development goals over a 15-year period Global security failing Focus on weapons as the primary way for protection What about focus on infectious diseases? How will the world protect itself? Ecological system rapidly eroding d/t irresponsible consumption patterns which as unsustainable “genuine interest in global health would extend to understanding our relationship with nature…” (p. 19) Benataur & Upshur  What needs to be done? Need coordinated, integrated health-care systems to health, wealth, and social well-being A basis for evaluating and improving national health-care systems globally Health security needs to be beyond pandemic planning but also around environmental toxins, bioterrorism, humanly engineered disasters Benataur & Upshur  What needs to be done? Addressing human-created problems Multidrug-resistant and extensively drug- resistant TB Water management Global political economy Benataur & Upshur Reimagining Global Health: Addressing Health Inequities: A Biosocial Approach to Global Health Health Disparities global health disparities on mortality rates, disability-adjusted life years (DALYs), and life expectancy. disproportionate burden of infectious diseases and non-infectious conditions in low-income countries. Social Determinants of impact of social determinants such as education, income, and social class on health outcomes. Health role of structural violence and social, political, and economic factors in shaping health disparities. global health delivery and its importance in providing equitable access to health interventions. Global Health Delivery need for comprehensive health systems in resource-poor settings and the role of interdisciplinary approaches in addressing global health challenges. need for broad-based social change to address the roots of ill health, including poverty, inequality, and Future Directions environmental degradation. importance of a biosocial approach, interdisciplinary analysis, and the vitality of praxis in reimagining global health for the future.  Unpacking Global Health: A Social Theoretical Toolkit Understanding the Complexities of Global Health Delivery Social theory is essential for understanding and interpreting the nature, effects, and limitations of medical and public health interventions. Well-intentioned global health and development projects can have unintended and undesirable consequences. The divide between theory and practice in global health has many roots, including the involvement of social scientists in enabling and justifying the violence of colonialism. Theories of Power and Authority Social theories help us understand the dynamics of power and authority in global health. Social Suffering and Structural Violence The concept of social suffering addresses the intersection of medical and social problems, highlighting the need for coordination of social and health policies. Structural violence, as observed by Paul Farmer, is "structured" by historically given and economically driven processes and forces that constrain agency. Social suffering and structural violence help deconstruct the roots of global health inequities and the political, economic, and historical forces that pattern and link material deprivation and poor health. Call to Action Social theory provides an organizational framework for global health, helping