Canadian Women's Health Network's Submission
To The Commission on the Future of Health Care in Canada

December 2001

CANADA HEALTH ACT

The CWHN resolutely supports the principles of the Canada Health Act and its expansion. Not only should the current act be maintained, it also needs to be extended to include home and community care and Pharmacare.

Therefore we urge the Commission's report include recommendations for:

1. A national Pharmacare Program and mechanisms to equitably manage access to medical technologies and new techniques. The CWHN believes there is strong evidence that a national Pharmacare program would reduce drug expenditures and increase health outcomes. This program should include:
   
   
   • A national program to develop and maintain an accessible Consumer Drug and Device Information Centre. Lay people need up-to-date, accurate, comprehensive and unbiased information on the pros and cons of all treatment options, drug and non-drug, as well as the option not to treat, for the health conditions and illnesses they face. A variety of organizations and groups including the Cochrane Collaboration, provincial Medical Technology Assessment units, and voluntary organizations working in health, such as the Canadian Women's Health Network, are addressing this issue.
     
     
   • Continued and enforced prohibition of Direct-to-consumer advertisements of prescription drugs -- given the lack of evidence of health benefits and the potential for harm and improper use of the health care system. See the report on Direct to Consumer Prescription Drug Advertising prepared by the Working Group on Women and Health Protection.9
     
     
   • The introduction of disincentives to reduce the impact of pharmaceutical advertising and "educational" activities on physician practice. This should include the introduction of a tax for pharmaceutical and device manufacturerers, which would in turn support the programs described here. These programs are expensive [includes free lunches, travel, salaries of promotional staff, sampling as well as advertising] and generally would fall into a category that is not taxable. In the United States, for example, pharmaceutical companies spend over $10 billion each year on drug promotion. Physicians are equally concerned about this. See for example the "NO FREE LUNCH" program -- www.nofreelunch.org/.
     
     
   • The development of an Adverse Drug Reaction reporting system that actively involves consumers. This should be a component of the surveillance and health protection systems of Health Canada -not one managed by the industry. [Experiences with Depo Provera, breast implants, electronic fetal monitoring lead us to have no confidence in private industry's capacity for leadership in this area].
     
     
   • The development a national mass purchasing system to reduce costs.
     
     
   • Establishment of a transparent management process for deciding whether drugs, medical technologies and techniques are to be part of Medicare services.

   Canadians are concerned that the current processes are not transparent, understandable and possibly inequitable. Recent challenges to provincial decisions by use of the human rights complaints attest to this. The burgeoning number of expensive new drugs and costly genetic tests should alert us to the need for this.

   Too often institution competitiveness, duplication of efforts and lack good outcome data hampers effective decision making. This will also require a credible process for communicating these decisions to the public and consumers. As well, compassion, a corner stone of health care, needs to be recognized and supported within the decision-making processes, as does the precautionary principle

   
   
2. National Home and Community Care program
   

   Early discharge, de-institutionalization and increasing numbers of Canadians living with chronic conditions have shifted more and more caregiving to community and to families-particularly to women -- as discussed earlier. The lack of a home care program unfairly discriminates against women.

   Throughout their adult lives, women are more likely than men to experience stress and overwork as a result of their multiple care and work responsibilities. The extent and nature of women's unpaid care-giving work and its stress and health impacts are only beginning to be understood. Saskatchewan research has shown that after only 18 months of continuous care giving, the health of 60% of unpaid caregivers begins to deteriorate10. Caregivers often sacrifice their own health due to their commitment to maintaining or improving another's quality of life.

   A national homecare program would have the advantages of a transparent and accountable delivery of service, quality standards for care, provisions of consistent levels of support and services. More importantly, this process would ensure that the recipients will have a place at the table and will be able to make their voices heard so that they may express their needs, concerns and complaints.

3. Development of financial compensation mechanisms for unpaid caregivers
   

   This should include the establishment of pension benefits and other financial supports for informal caregivers, as well as better family leave programs. These are important components of healthy social policy. Better family leave programs would address some of the negative affects on the caregivers' own health and well-being. In addition, the vast majority of these informal caregivers are women who should receive some form of income loss compensation.

   Janice M. Keefe, Ph.D. and Pamela J. Fancey, M.A., of Mount Saint Vincent University, in their 1998 report, Financial Compensation Versus Community Supports: An Analysis of the Effects on Caregivers and Care Receivers, stated that, "Direct payment to caregivers serve to reinforce social values of helping and caring, values which have become increasing more difficult to realize as a result of changing family demographics." We recommend that:
   
   

   • Financial compensation in the form of a direct payment be considered as a way to recognize and support family caregivers.
     
     
   • Direct compensation in the form of a caregiver allowance be further investigated through a pilot program to measure its effectiveness on sustaining the care-giving relationship.
     
     
   • Financial compensation and services availability should be viewed as complementary. Compensation should not be viewed as an alternative to services but one of a range of supports in the development of a comprehensive and flexible approach to meeting the needs of caregiver.11
     
   
   
4. A National program on health promotion and disease prevention
   

   It has been well documented that strong health promotion and disease prevention programs make for a healthier population. A healthier population relies less on expensive medical treatments and interventions. Currently these programs are fragmented and temporary in nature. This program should provide:
   
   

   • Support for citizen self help, mutual support and action groups on health. It has been hard for community groups to maintain themselves since federal cutbacks in this area. A side effect of the federal cutbacks to citizen organizations has been increasing linkages and funding which comes from the pharmaceutical industry. Whether intended or not, these relationships influence the advocacy and policy advice components of these groups activities. Conflict of interest issues arise. This also encourages disease-focused groups to dominate the landscape, as there are few "partners" for healthy public policy and meaningful prevention programs.
     
     
   • Support broad public, community and targeted health promotion and education programs. Strategies must address the links between risk factors and the non-medical health determinants. This should include education and other programs regarding critical structural determinants of health. This will ultimately strengthen public acceptance and implementation of important healthy public policy.
   
   

   Note: The promotion of "wellness" should not mean that we shift all responsibility for health to the individual. We cannot ignore the fact that poverty, social and working conditions are the strongest determinants of a person's health status. We need social and economic policies that reduce poverty and otherwise address healthy public policy.

5. The Federal Government negotiate a general exclusion of health services from all trade agreements and that patent protection only be granted after a careful review of the impacts on health status and health services.

   It is clear that despite initial assurances, global agreements such as NAFTA and legislation such as the Patent Act can have a real effect on health services and knowledge.

   • For example with NAFTA, it will be difficult to undertake national programs such as Pharmacare and Home Care, without an exclusion, since for-profit companies with international ownership operate within Canada.
     
     
   • A review of Patent protection is needed as existing policy has had, and will continue to have significant impact on Canadians. To date this has been most apparent in the escalating cost of new pharmaceutical products. We only need to look to at the recent example of genetic testing for breast cancer, (i.e. BRCA1 and 2), to reliance that the impact of patenting will affect more than drug prices. For example with BRCA1, Myriad Genetics introduced what can be only described as extreme costs and procedural requirements that led to the de-listing of the procedure in British Columbia and Ontario. This issue has yet to be resolved.12
   
   
6. New models of engaging the Canadian public in health services and increasing their capacity to make informed decisions about their health and health care.
   

   The CWHN strongly encourages the Commission to enshrine in its values a commitment to empowering citizens and to the development of new models of service delivery. This would ensure that policies and services are responsive and accessible to the needs of the population.

   There are successful models that exist, especially in the women's community, and they include the following approaches:

   • Processes that encourage a partnership between the woman/client and her caregiver. Staff and volunteers de-emphasize differences between consumer and care provider, and seek to develop a partnership with her/him in addressing her/his health issues.
     
     
   • Consumer centred services: The consumer, in the context of her/his community is the centre of service and planning. For example Community health centers with boards of directors drawn from the clients the clinic serves are excellent models of this form of service delivery.
     
     
   • Access to better health information. Canadians have continued to articulate a desire for increased access to credible information, i.e. the full spectrum of information on health conditions, treatment options, health outcomes, and healthy public policy; support for self care activities; and mechanisms to participate in health service planning. Although there are some exciting local examples, there have not yet been systemic changes that would make this goal reachable. Support for voluntary sector organizations working in health and expansion of models such as Info Sante and expansion of the mandate of the Canadian Health Network to provide Drug and treatment information would support this work.
     
     
   • Team approaches: Interdisciplinary teams of health care providers working collaboratively, including professional, paraprofessional and volunteer staff are most effective in meeting women's needs.
     
     
   • Use of peer volunteers: Peer volunteers play a key role in promoting the empowerment of clients through modeling self-help skills, demystifying medical information, and bringing community perspective to the design and delivery of services.
     
     
   • Community involvement: Working in partnership with various communities concerned about health, building on the strengths and interests of partners, including volunteers, clients, service provider or other members of the community are important approaches.
     
     
   • Innovative program development: Continuous development and re-focusing of services approach based on new understandings of consumer's needs and issues includes collaborating with community women and researchers, and integrating newly gained knowledge.13
   
   
7. Requirement of gender-based analysis (GBA) to service delivery and planning.
   

   GBA is described as an analytical tool that uses sex and gender as an organizing principle or a way of conceptualizing information. It provides a framework that recognizes that women and men are not the same and that policies and practices impact them differently. It also allows for a diversity analysis that considers such factors as race, ethnicity, level of ability and sexual orientation.

   GBA makes for healthy public policy as it recognizes the need for participation of women and men in decision-making and gives equal weight to the knowledge and experiences of both genders. Further, gendered statistics requires that all official data include a breakdown by sex including differences in health status, outcomes, success, utilization, etc. and be analyzed carefully to reflect the influence of gender issues. Qualitative methods of data collection also provide a particularly valuable perspective, as women's voices are an important part of evidence.

   As a result of International Agreements, Health Canada has recently committed to the implementation of GBA throughout the department 14. This approach will ensure that all policies, programs and legislation that reviewed or developed will be in the best interest of ALL Canadians. It is unclear what impact this process will have on direct service delivery at the provincial level. Research produced by the Prairie Center of Excellence in Women's Health has demonstrated that without gender analysis, women's issues and perspectives can be missed in regional planning processes despite the belief that these processes are more community based 15. . Recently the Province of British Columbia has released a new document "Gender-Inclusive Health Planning: A guide for Health Authorities in British Columbia that could be used as a model 16. Quebec has also undertaken a similar project but it is as yet not complete.

   There are many models of successful women centred care throughout the country for which GBA is a central component of their functioning. Essentially, these models recognize the importance of empowering of women and encourage their involvement health service and program planning, implementation, evaluation, policy and research. They also acknowledge that women face additional barriers in accessing health services and as such strive to ensure that programs are respectful, safe and meet consumers' needs. Some provinces or regional health boards have developed their own models e.g. Vancouver Richmond Regional Health Board's Framework for Women Centered Care 17 or the Women's Health Clinic 18 in Winnipeg but this is inconsistent.

   Therefore, it is important that gender based analysis become a mandated activity.

8. Recognizing complementary and alternative methods of care
   

   More and more Canadians are turning to alternative and innovative therapies in order to care for various chronic conditions and maintain their health. Our multicultural society has a variety of traditions and experiences to draw on and to which Canadians will seek access. These include for example, traditional Chinese medicine, traditional Aboriginal healers, ayurvedic medicine, and naturopathy.

   As well, access to dentistry and counseling services remain on fringe of health services. We will need flexible mechanisms to allow for individual choices and access to culturally sensitive care within the context of population health and health needs, and assurance that these will be high quality services and treatments.

   Those who use alternative therapies state that they fit better with their values and beliefs about life and health. As well, these methods assess the whole person and use natural means to help the body heal itself. While there are many alternative and complementary therapies that have been used safely for generations and have proven their efficiency, there are many that exist outside public accountability and lack evidence of their effectiveness.

   As such, the Commission's report should recognize these phenomena and develop recommendations for addressing these needs. This should include:

   • Establishment of transparent processes for the evaluation and accreditation of complementary and alternative care providers and their treatment modalities where they do not already exist.
     
     
   • Support for research and demonstration project funding for alternative health care providers as part of an integrated health care team.
     
     
   • Medical, midwifery and nursing schools offer courses in alternative and complementary methods of care.
   
   
9. Establishment of mechanisms for addressing the Determinants of Health and Health Inequities. These mechanisms should include:
   
   
   • Requiring that Health Impact Assessments as part of the government operations and policies.
     
     
   • Establishing a Health Commissioner to monitor and report on the impact of government policy on health. This is an area where knowledge uptake and evidence based decision making is needed, particularly involving senior staff in all departments. At times we do not have a knowledge gap so much as we have an "action gap".

   There is now a well-established positive connection between income and health. Newer research has shown a connection not only between income and health, but also between societal income inequalities and health. That is, those societies with greater economic inequalities have higher death rates than more egalitarian societies. This is important because it points to our interdependencies as members of a community 19. The costs of social exclusion and health inequities are experienced by everyone.

   However, women form the majority of the poor in Canada. One in five Canadian women live in poverty - that's 2.8 million women" 20. Further, sole support, widowed and single older women, aboriginal women, women with disabilities and women from visible minority groups are especially vulnerable to living in poverty.

   Understanding women's socioeconomic status is more complicated than for men because women earn significantly less than men, they have lower labour market participation rates, are more likely to work part time and may temporarily leave the labour force while raising young children.

   Recent analysis of Canadian data by Margaret Denton and Vivienne Walters has shown that the connection between income and health is stronger for women than for men, both for measures of self-perceived health and of functional health. This contrasts with earlier work which typically found that smaller socioeconomic inequalities for women than for men. Denton and Walters also found that the structural determinants of health, including socioeconomic status, had a greater impact on women's health than the behavioural determinants of health - lifestyle factors such as smoking, alcohol consumption, physical activity and weight. Again this points to the importance of addressing income inequalities in order to improve the health of women.

   Currently governmental policy and programs are not evaluated for their impact on health status of the population despite what is known about the links between socio-economic status and health. This is not well understood by the general public or policy makers. It is unclear why we require environmental impact studies but not ones related to health impacts.

10. Precautionary principle
    

    The CWHN recommends that the Commission include the precautionary principle as a fundamental value in a renewed health care system. The "precautionary principle" is an approach which states that when there is uncertainty about an activity, policy or procedure, the onus should be on those who wish to carry it out to demonstrate in advance its lack of harm. (This contrasts with the more common approach of endorsing an activity until such time as one finds harm.) This is especially important in the regulation of drugs, tests and devices. This principle should be part of the renewed values and vision of health care.

11. Improved education, recording, reporting and monitoring be at the heart of health care reform. This should include:
    
    Consumers/Public/Patients/Clients
    
    
    • Patients have access to best-quality, easy-to-assimilate information on their health status and treatment choices that are appropriate to their gender and other personal characteristics. Risks and benefits for each treatment are fully explained to the patient by the health care team as well as the benefits and risks of doing nothing.
      
      
    • Information about the quality and outcomes of the health care institutions and providers and possible models of service delivery.
      
      
    • Population health information about their community and the impact of governmental policy on health.
    
    Policy makers
    
    
    • Policy makers have access to patient care and cost benefit information in aggregate form to protect patient privacy, and information on the priorities, interests and values of their constituents. Longitudinal studies and projections are readily available, and an effective forum for stakeholder debate and involvement exists.
      
      
    • Once a year, governments should issue a Report card on women's health. This report would document the state of women's health at the national and provincial levels and would explore the policies that impact either positively or negatively on women's ability to enjoy good health. This process would allow for accountability and would put a focus on women's health issues. An example of such a Report card can be found on the Oregon Health and Science University Women's Health Center web page www.ohsu.edu/women/ReportCard.htm.
    
    Service providers
    
    
    • Administrators of health care services and institutions including home care, mental health and community health have access to longitudinal and comparative data on service variations. Short- and long-term performance indicators exist. Integrated, linked information on socioeconomic indicators, medical and non-medical determinants of health, utilization costs and health care capacity are available. Information systems provide comparative analyses across planning areas, leading to the understanding of the relative contributions of non-medical and medical inputs to health; the linkage of information to current funding and delivery perspectives; and the flexibility to provide focused responses to well-articulated policy questions.
      
      
    • Providers have access to high-quality patient care evidence at the point of care. The evidence is as specific to the situation as possible taking all relevant differences, including gender and culture, into consideration. Information on standards of practice and cost evaluations are readily available. High-quality evidence, with appropriate incentives and tools, enables adoption of new approved standards of practice. Health and medical records distributed over a number of institutions and organizations are accessible as needed through information technology, which guarantees privacy and confidentiality of patient records.

In conclusion, we would like to thank you for the opportunity to share our thoughts and to present our position to the Commission on the Future of Health Care in Canada. The Commission is in a unique position to ensure that our health system remains founded on equity, need and accessibility for generations to come.

9   Working www.web.net/~desact/anglais/anglais.html
10  National Film Board of Canada, Until the Day Comes, 1990
11  Women's Health Clinic's Brief to The Standing Committee on Social Affairs, Science and       Technology www.cwhn.ca/resources/whc-brief/index.html
12  Women's Health Clinic's Brief to The Standing Committee on Social Affairs, Science and       Technology www.cwhn.ca/resources/whc-brief/index.html
13  Women's Health Clinic's Brief to The Standing Committee on Social Affairs, Science and       Technology www.cwhn.ca/resources/whc-brief/index.html
14  Women's Health Bureau, Health Canada, Guide to Gender-based Analysis       www.cwhn.ca/resources/gba/gender.pdf
15  Invisible Women: Gender & Health Planning in Manitoba & Saskatchewan and Models for       Progress T. Horne, L. Donner and W.E. Thurston (1999) www.pwhce.ca/pdf/iv.pdf
16  Ministry of Health Services www.healthservices.gov.bc.ca/whb
17  http://www.vcn.bc.ca/vrhb/Down_Loads/Womens_PHAC/WomenCentredHealth-Jun-2001.pdf
18  See www.womenshealthclinic.org for ordering information
19  Women's Health Clinic, Women, Poverty and Health in Manitoba: An Overview and Ideas for       Action, July, 2000, www.cwhn.ca/resources/women_poverty/summary.html
20  CRIAW