Module 2

Question 1

Healthcare delivery

Answer 1

the manner in which medical services are
organized, managed and provided. Can be:
* Public
* Private
* Mixed

Question 2

Healthcare financing

Answer 2

the manner in which funds are raised, pooled,
mobilized and used to purchase healthcare services. Can be:
* Public (e.g. from taxation)
* Private (e.g. from private insurance)
* Out-of-pocket

Question 3

Canadian financing and delivery

Answer 3

*In general, most healthcare in Canada is publicly funded, but
privately delivered
* There are exceptions, as we will see in future modules
*This means that while most of healthcare services are “free” at
the point of use, they are delivered by private providers (i.e.
physicians) who bill public insurance plans for the services
they deliver

Question 4

Public health &
most hospitals

Answer 4

Public
financing
Public
delivery

Question 5

Physician services

Answer 5

Public
financing
Private
delivery

Question 6

Dental care, vision
care, rehab etc.

Answer 6

Private
financing
Private
delivery

Question 7

What is policy

Answer 7

Policy “a set of interrelated decisions taken by a political actor or group of actors
concerning the selection of goals and the means of achieving them within a
specified situation where these decisions should, in principle, be within the
power of these actors to achieve.” (Jenkings 1978, as quoted in Deber)
◦ Decision makers typically consider: personal beliefs, values, evidence, factors such as
elections and recessions, stakeholder pressure and institutional constraints
◦ Implicit assumption that process for policy making is linear/proceeds in a clear cycle not
always the case
◦ Policy can involve deciding not to change anything
Models and frameworks may help us understand these complex processes
◦ May help us both to understand past choices, and plan for future implementation
More on this later this module. . .

Question 8

Policy cycles

Answer 8

1. Objectives
2. Policies
3. Instruments
   and tools
4. Decision
   making
5. Program
   implementation
6. Benchmarking/
   monitoring
7. Evaluation
   In reality, much more complex and messy

Question 9

Health legislation

Answer 9

“the body of rules that regulates the promotion
and protection of health, health services, the equitable distribution
of available resources and the legal position of all parties concerned,
such as patients, health care providers, health care institutions and
financing and monitoring bodies” (Leenan, 1998).
Most policies are not legislation/laws. They can be easily changed if
they are not supported as policy objectives in legislation (Legemaate,
2002).

Question 10

Examples of relevant health legislation

Answer 10

◦In BC:
◦ Mental Health Ac
◦ Public Health Act

◦In Canada:
◦ Canada Health Act
◦ Bill C-14

Question 11

Federalism

Answer 11

Federalism is a political system
Powers of government are split
between federal and
provincial/territorial levels
◦ Feds have jurisdiction over the whole
country
◦ Provinces have jurisdiction over their
population and region
Specific authorities/responsibilities
assigned to the federal and provincial
governments is the division of powers

Question 12

Division of powers

Answer 12

initially established through the British North America Act (1867),
though there were few specific mentions of healthcare:
◦ Feds “quarantine and the establishment and maintenance of marine hospitals”
◦ Provinces “the establishment and management of hospitals, asylums, charities and eleemosynary
institutions”
Subsequent constitutional interpretations have placed major responsibility for health
measures and services on the provinces
1982 Constitution Act reaffirms division of responsibilities

Question 12

Fiscal Federalism

Answer 12

• As it pertains to healthcare, intergovernmental relations are defined by fiscal
  federalism
• Health care is primarily provincial domain
• Federal governments contributes fiscal support (through the Canada Health Transfer (CHT))
• The Canada Health Act sets out rules and a national ‘minimum standard’ for
  provincial/territorial insurance plans for provinces to receive the CHT
• More on this in the next video…
• In more recent history, conditional transfers (funding packages) have been delivered to
  promote improvement in key areas of service delivery: e.g. wait times, electronic medical
  records, telehealth, primary care access
• The result is 13 public single-payer provincial/territorial insurance schemes that
  are distinct but similar

Used to share costs 50/50 with provinces
◦ Non-medicare (CHA) services (long-term care, drug coverage) constituted
roughly 40% of total provincial and territorial health expenditures in 2011,
compared with 23% in 1975
To summarize: the Federal government sometimes uses money to 1)
set the minimum shared standards for publicly insured care in the
provinces/territories and 2) set “encouraged” directions for health
care, but this varies depending on the government in power

Question 13

Federal Role

Answer 13

*We have already established that the main role of the federal
government is to:
* Assist in financing provincial and territorial healthcare services through
fiscal transfers.
* Set standards and principles upon which transfers are contingent.
*They also:
* Deliver healthcare services to specific groups.
* Provide and fund other health-related functions.

Question 14

Federal Government:
Health Canada

Answer 14

Responsible for helping Canadians maintain
and improve their health
* Regulates product safety
* Reduces illegal drug/tobacco use
* Reduces environmental risks
* Provides health information
*Ensures that high-quality health services are
accessible and works to reduce health risks
*Federal institution, headed up by the
Federal Minister of Health

Question 15

Federal
Government: PHAC

Answer 15

Public Health Agency of Canada (PHAC): responsible for public
health, emergency preparedness, and responses to infectious
and chronic disease control/prevention
◦ Disease control and detection
◦ Health Safety
◦ Travel Alerts
◦ National immunization and vaccination initiatives
◦ Emergency preparedness
◦ Health Promotion
◦ Injury Prevention
◦ Research and statistics
Two central locations:
◦ Ottawa
◦ Winnipeg, Manitoba – only level 4 microbiology lab in
Canada

Question 16

Federal Government: CIHR

Answer 16

Canadian Institutes of Health Research
(CIHR): major federal agency responsible for
funding health research in Canada
Embraces 4 pillars of research:
1. Biomedical
2. Clinical
3. Health Systems and Services
4. Social, cultural and environmental factors
and population health research

Question 17

Federal Government: Patented
Medicine Prices Review Board

Answer 17

Patented Medicine Prices Review Board (PMPRB):
arms-length quasi-judicial body
Protects consumers by ensuring manufacturers’ prices
of patented medicines not “excessive”
◦ Establishes maximum price that drugs can be sold at:
◦ Only for patented drugs
◦ Generic drugs at provincial discretion
◦ No jurisdiction over prices charged by wholesalers
or pharmacies, or fees charged by pharmacists

Question 18

Federal Government:
Statistics Canada

Answer 18

Federal agency charged with
producing statistics to understand
Canada
◦ Produces stats for federal, provincial
and regional use
◦ Not limited to health
◦ Canadian Community Health Survey is
one key health-related activity

Question 19

Federal government: Indigenous Services Canada (Formerly First Nations and Inuit Health Branch of Health Canada)

Answer 19

Public health and health promotion services on-reserve
and in Inuit communities
Supplemental coverage for “non-insured health benefits,”
e.g.:
◦ Prescription drugs
◦ Dental care
◦ Vision care
◦ Medical transportation to services not provided onreserve or in the community of residence
◦ Population health and community health programs
Primary care services on-reserve in remote and isolated
areas, where there are no provincial services readily
available

Question 20

Provincial Government

Answer 20

*Administer their health insurance plans
*Delivery of:
◦ Hospital care
◦ Physician care
*Also provide (to some degree)
◦ Institutional and community care
◦ Palliative are, post-operative care, home oxygen, long term care assessment, home care, rehabilitation
◦ Drug plans for those without access to Private Health Insurance
*Negotiation of fee schedules with health professionals

Question 21

Health services in Canada are
Highly decentralized, because of

Answer 21

◦ Provincial/territorial responsibility for funding and delivery
◦ Many organizations within provinces that operate at arm’s length from
provincial government
◦ Health Authorities, privately-administered hospitals, organizations to delivery home and community
care, etc.
◦ Status of physicians as independent contractors

Question 22

The Canada Health Act (CHA)

Answer 22

Federal legislation that sets primary objective of Canadian health
policy: “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.”
The Act specifies criteria/conditions related to health insurance that
provinces/territories must conform to in order to receive federal
transfer payments (Canada Health Transfer)
Canada Health Act is mostly about health care financed

Question 23

Criterion 1: Public Administration

Answer 23

8(1). In order to satisfy the criterion respecting public administration
a) the health care insurance plan of a province must be administered and
operated on a non-profit basis by a public authority appointed or designated
by the government of the province;
b) the public authority must be responsible to the provincial government for that
administration and operation; and
c) the public authority must be subject to audit of its accounts and financial
transactions by such authority as is charged by law with the audit of the
accounts of the province.”
Applies to health care insurance plan, not service delivery

Question 24

Criterion 2: Comprehensiveness

Answer 24

“9. In order to satisfy the criterion respecting comprehensiveness, the health care insurance plan of a province must insure all insured health services provided by hospitals, medical practitioners or dentists, and where the law of the province so permits, similar or additional services rendered by other health care practitioners.” Provinces allowed but not required to insure additional services Provinces decide beyond physicians what “other health care practitioners” qualify for payment under the Act ◦ E.g. midwives, nurse practitioners

Question 25

Criterion 3: Universality

Answer 25

“10. In order to satisfy the criterion respecting universality, the health care insurance plan of a province must entitle one hundred per cent of the insured persons of the province to the insured health services provided for by the plan on uniform terms and conditions.” All insured persons must be covered for services provided by the plan on uniform terms and conditions ◦ Only applies to “insured persons” ◦ Only applies to “insured health services”

Question 26

Criteria 4: Portability

Answer 26

“11(1). In order to satisfy the criterion respecting portability, the health care insurance plan of a province (a) must not impose any minimum period of residence in the province, or waiting period, in excess of three months before residents of the province are eligible for or entitled to insured health services; (b) must provide for and be administered and operated so as to provide for the payment of amounts for the cost of insured health services provided to insured persons while temporarily absent from the province …; and (c) must provide for and be administered and operated so as to provide for the payment, during any minimum period of residence, or any waiting period, imposed by the health care insurance plan of another province, of the cost of insured health services provided to persons who have ceased to be insured persons by reason of having become residents of that other province, on the same basis as though they had not ceased to be residents of the province.” Residents moving will be covered by previous province for 3 months before new province picks them up

Question 27

Criteria 5: Accessibility

Answer 27

“12(1). In order to satisfy the criterion respecting accessibility, the health care insurance plan of a province (a) must provide for insured health services on uniform terms and conditions and on a basis that does not impede or preclude, either directly or indirectly whether by charges made to insured persons or otherwise, reasonable access to those services by insured persons; (b) must provide for payment for insured health services in accordance with a tariff or system of payment authorized by the law of the province; (c) must provide for reasonable compensation for all insured health services rendered by medical practitioners or dentists; and (d) must provide for the payment of amounts to hospitals, including hospitals owned or operated by Canada, in respect of the cost of insured health services Insurance plan must provide “reasonable access” to insured services ◦ Reasonable access and reasonable compensation are NOT defined (not just about cost) ◦ Supposes that provincial negotiations with provider groups satisfy condition of reasonable compensation

Question 28

The Conditions 1. Information (section 13(a))

Answer 28

The provincial and territorial governments are required to provide information to the federal Minister of Health as prescribed by regulations under the Act.

Question 29

The Conditions 2. Recognition (section 13(b))

Answer 29

The provincial and territorial governments are required to recognize the federal financial contributions toward both insured and extended health care services.

Question 30

“Medically necessary”

Answer 30

◦ The CHA does not define “medically necessary” ◦ Defined by provinces and medical physician colleges ◦ The CHA sets terms and provinces must meet to receive funding for hospital and doctor’s services ◦ Paying costs of hospital stays and doctor visits is the easiest to meet This doesn’t mean provinces can’t cover other services ◦ Does mean that services outside core CHA are inconsistent across jurisdictions

Question 31

Policy Objectives Four key objectives that are often conflict with each other:

Answer 31

◦ Security ◦ Liberty ◦ Equity ◦ Efficiency (Stone, D. 2011)

Question 32

3-I’s Framework

Answer 32

Interests: “agendas of societal groups, elected officials, civil servants, researchers, and policy entrepreneurs” (Pomey et al., 2010, p709) Ideas: “knowledge or beliefs abut what is…, views about what ought to be…, or combinations of the two” (Pomey et al., 2010, p709) Institutions: “the formal and informal rules, norms, precedents, and organizational factors that structure political behaviour” (Pomey et al., 2010, p709)

Question 33

Interests

Answer 33

Who wins and who loses? By how much do they win or lose? Have groups mobilized around specific interests?

Question 34

Ideas

Answer 34

What sources of evidence might be used? By whom? ◦ How would you describe this evidence (strong, weak, complex, consensual, uncertain, controversial)? What values and ideologies may come into play? ◦ Societal values ◦ Ideology of the government ◦ Values or ideology of professional groups

Question 35

Institutions

Answer 35

How might the following shape, reinforce, or constrain policy developments and choices: ◦ Government structures (political arrangement and accountability structures)? ◦ Policy networks (relationships between government and outside actors)? ◦ Policy legacies (past policies and ‘path dependence’)?

Question 36

Path dependence and policy legacies

Answer 36

The range of options available is limited by choices made in the past, even when the circumstances giving rise to those circumstances are no longer relevant (Can think of this as a type of institution)

Question 38

But… it’s not always so clear

Answer 38

◦ Fee-for-service compensation model – institution ◦ Fee-for-service compensation model is the best way to support physician autonomy – idea ◦ Doctors who are grumpy moving away from fee-for-service because of perceived threats to autonomy – interest