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Canada's Federal and Provincial Health Care Inquiries: 1940s to 2003

TIPS-95E
January 21, 2003


A Long Tradition of Inquiry 

Romanow Commission’s Mandate:

“recommend policies and measures respectful of the jurisdictions and powers in Canada required to ensure over the long term the sustainability of a universally accessible, publicly funded health system, that offers quality services to Canadians and strikes an appropriate balance between investments in prevention and health maintenance and those directed to care and treatment.”

In April 2001, when the Commission on the Future of Health Care in Canada was established under Part I of the federal Inquiries Act, public response varied from wholehearted enthusiasm to cynicism about the merits of another study.  Under a sole commissioner, Roy J. Romanow, this Commission received a broad-ranging and multi-dimensional mandate similar to the task faced by preceding investigations into health care.

The Romanow inquiry joins a long tradition of federal and provincial bodies seeking to build and shape an efficient, equitable and sustainable health care system for Canadians. Given the topical nature of the discussions about this federal health inquiry and other efforts to examine health care at the federal and provincial governmental levels, this document aims to provide contextual background about past health inquiries, their subsequent reports and the challenges underlying any responses.

The Nature of Inquiries

From the 1940s to the present, federal and provincial governments have used multiple mechanisms to study existing health care situations.  In particular, they have relied on commissions of inquiry and ministerial advisory groups as well as committees of Parliament and legislatures when initiating, collecting and conveying new values about and solutions for health and health care.

In general, inquiries into health areas have fulfilled certain functions and met many of the diverse needs of the governments that established them.  They have served as a mechanism to:

  • secure an informational base for policy decisions,
  • evaluate established policy to identify areas for change,
  • create public support and pressure for intended legislation,
  • facilitate debate over conflicting values,
  • test for public preferences to guide politicians and bureaucrats in policy decisions,
  • enable the government to postpone difficult or potentially embarrassing decisions.

Various limitations of such inquiries have also been identified. For example, when established, the examinations were carried out in a pre-set time period, requiring members to produce a complex report within a narrow timeframe.  There was also the fact that inquiry appointees had no authority or mechanism for implementing their own recommendations.  In addition, because the governments establishing the inquiry bodies framed the underlying questions, the development of ideas could be restricted and the questions could be applied in ways that excluded certain interests.  Furthermore, the appointment of members on the basis of varying criteria including political and regional considerations could diminish effective participation by those with knowledge.

For governments, relevant groups and interested Canadians, the multiple health commissions, advisory groups and committees initiated to explore the dimensions of Canada’s health care system have provided an important access point to legitimize and publicize shared concerns.  All have seen such forums as an important step in initiating and developing health policy and in establishing the parameters for possible legislation.  They have recognized that the inquiries created a public climate favourable to change and indicated governmental intention to take action.

Health Inquiries Over the Decades:  Context and Direction

With every decade, significant reports – each the product of a particular political, economic and social context and each contributing to the shape of the current system – have emerged.  The questions underlying these reports focused on creating and sustaining publicly insured services and asked repeatedly how such services should be organized and funded; who should provide them; where they should be delivered; and when they should be adapted to changing conditions.

The foundation activities of the 1940s and 1950s took place against a backdrop of wartime, with a focus on social commitment and responsibility.  Many of the early themes were reiterated, however, in successive decades.  The 1970s and 1980s saw a continued push for the development of health services that would provide a high standard of preventative and curative care while being fair both to the insured and to those providing the services.  By 2002, economic costs persisted as a major concern of all governments.

   Rooting Medicare:  The Early Years

  • 1940s – This period saw considerable cross-country action with various proposals aimed at building a national system of health care.  Federally, there was a newly constituted health and welfare department, reports on health insurance from an interdepartmental advisory committee as well as a House of Commons committee, and a National Health Grants Program offering cost-shared support to the provinces for planning and organization, public health, and hospital construction.  While several provinces moved to set up health service commissions and medical care services, it was Saskatchewan that took the most visible steps by establishing, first, a special select committee; then, a commission; and ultimately, a hospital plan for residents.
  • 1950s – Federally, interest at this time was directed more toward a plan for national hospital insurance than for physician services.  In January 1958, the Hospital Insurance and Diagnostic Services Act established a cost-shared plan; by 1961, all provinces were participants.  The provinces also used the 1948 federal health grants for survey reports on existing facilities and future needs.  The provinces differed in their approach:  several simply provided overall reviews of health facilities and services, while others went further and made significant recommendations about prepaid hospital and medical care, training for doctors and nurses, and arrangements to cover less populated areas.
  • 1960s – Although not eager to confront organized medicine with a national medical insurance program, the federal government saw that both the program of health grants and the hospital insurance legislation encouraged a reliance on expensive hospital care and diagnostic services.  The establishment in 1961 of a federal Royal Commission on Health Services led to a final report that gave shape to an overall national system.  The inquiry report provided guiding principles and arguments for government-sponsored, comprehensive and universal health services through cost-sharing agreements between the federal government and the provinces where funding would cover hospital, medical and other services, including prescription medications and home care. By 1966, in response to both rising health-care costs and the Royal Commission’s recommendations, the federal government introduced the Medical Care Act, extending federal cost-sharing to medical insurance plans covering physicians’ services.  In 1972, the national plan included all provinces and territories.

   Refining Medicare:  The Maturing Years

  • 1970s – Provincial and federal studies called for changes to existing practices in health education and human resources, facilities and services, and overall organization at the community, professional and institutional levels.  They identified rising expenditures, system inefficiencies, and uncontrolled deployment of personnel, and suggested remedies such as regionalization and deinstitutionalization. By 1977, the federal government had changed the conditions of transfers to the provinces from a cost-shared to a per capita arrangement under Established Programs Financing (EPF).  This period also saw a stronger focus on ways to keep Canadians healthy, with reports building on Quebec’s community health centres initiatives and on arguments for changes in the social and physical environments.
  • 1980s – An early federal report reviewing health services argued that user fees and extra-billing violated the accessibility principle and recommended that stronger measures be taken to prevent uneven costs for care. The Canada Health Act, enacted by the federal government in 1984, consolidated the provisions of the two previous insurance Acts and reaffirmed the principles – public administration, comprehensiveness, universality, portability, and accessibility – underlying the national programs.  Within three years, all provinces had complied with the Canada Health Act.  Cost constraints imposed by federal revisions in transfer policies led provinces to reconsider their approach to service delivery.  Multiple provincial reports reached similar conclusions, and common themes in 1980s provincial reports included recommendations to:
  • keep health care resources at the same level but change the way they are managed and allocated,
  • define health to address related issues beyond medical care, such as education, housing, employment and the environment,
  • move from institution-based care to community-based care and provide more opportunity for individuals to participate in health decisions with service providers,
  • work for better regional management of services and human resources, including physicians, for greater efficiency and effectiveness in the system, and evaluate medical practice and delivery systems. 

   Revising Medicare:  The Modifying Years

  • 1990s – New financing arrangements, as well as conceptual work concerning population health and determinants of health, reshaped health care thinking.  A federal block grant to the provinces, the Canada Health and Social Transfer, began in 1996-1997.  By 1997, the federally appointed National Forum on Health concurred with the earlier provincial assessments that the fundamental principles underlying the funding system for health care and enshrined in the Canada Health Act were sound.  It also called for adaptations to the system to include home care, pharmacare, and primary care reforms.  This did not hinder several provinces from initiating their own efforts to re-examine and reorganize their systems.  Ontario oversaw major changes to the public hospital system and other health care components.  Alberta sought public input into changes to the delivery and management of health services, individual responsibility for health, and funding to sustain the public system.

Some Challenges Facing Inquiries

Over the seven decades of Canadian health care studies, there have been multiple challenges for those producing the reports and for those responding to them.  The challenges relate to the nature of the inquiries themselves, to Canada’s multi-tier government, and to the complexities of health as a policy area.

  • The Nature of Inquiries

The reports and recommendations that are the most tangible products of inquiries and health studies are not accompanied by any legal requirement for government action.  Thus, the reports resulting from the health inquiries served as blueprints for subsequent action, but follow-up actions were seldom taken immediately.  As with other efforts to analyze and pronounce on public policy, governments took time to weigh the options put forth in a report and to assess the level of public support for any proposed changes before implementing the recommendations.

  • The Multiple Levels of Health Governance

Partly due to jurisdictional divisions, federal inquiries may have little direct effect on provincial delivery of health services.  Thus, while provincial reports often resulted in direct and obvious actions, the federal reports frequently required years of intergovernmental negotiations before producing change.  However, the provinces’ desire to have some form of harmonized systems and the provincial need to seek federal funds often gave weight to federal reports.  The overall desire to redirect the system toward improved health outcomes and increased accountability led both federal and provincial reports to recommend more involvement by local community-based bodies.  The rationale was that people at a regional or local level were better placed to respond to the diverse health needs of the community than bureaucrats in a remote provincial or federal department.  Questions remain about whether financial, as well as management, control can be effectively devolved in a country with multiple tiers of government.

  • The Complexities of Health and Health Care

From the early health inquiries to the recent ones at both federal and provincial levels, key themes relating to financial resources, human resources, organization of services, and so on appear consistently and repeatedly, with incremental changes in each decade.  In part, this is related to the narrow but firmly established hospital and physician base of the health care system.  The current policy debates continue to raise questions about how to identify and act on shared values, how to shift from health care to health, how to control costs while sustaining publicly accessible health care, how to organize health providers and health services appropriately and how to measure, track and report on performance. 

Whither Inquiries?

As a country, Canada faces increasingly complex health policy challenges related to, among other things, constitutional divisions of power, geographical diversity, socio-economic divisions, and international pressures.  The development of the current philosophical, structural and operational underpinnings of Canada’s health system has a lengthy and still evolving history.  As governments across Canada continue their search for answers to various health policy quandaries, they often demonstrate their concern by setting up an officially recognized body to conduct an in-depth appraisal, thereby continuing a pattern established over many decades.

  • Opportunities for Directed Learning

Overall, these inquiries provided opportunities for continual public and governmental learning.  New perceptions and insights emerged that could be applied to analyzing policy problems, to developing options and to adapting the health care system.  Inquiries have often helped to rank, balance, and otherwise illuminate the relation among ideas and interests and their relevance to change in the health field.  With governments facing constant challenges from economic, political, ethical and other forces, inquiries have assisted them in finding more consistent and achievable directions.

  • Proposals for Innovation and Implementation

When faced with innovative suggestions for change, governments have had to address certain institutional realities that controlled the extent to which new ideas could penetrate and organized interests could influence public policy outcomes.  Nonetheless, the reports of commissions and committees served as valuable policy proposals, the first stage of the process.  If the proposals were to become active, they had to be adopted, implemented, and enforced through governmental institutions.  For inquiries to be effective, the move from creative plan to practical solution, from innovation to implementation, required public persistence and governmental determination.

Prepared by
Nancy Miller Chenier, Acting Principal
Parliamentary Information and Research Service
George Ekins, Librarian
Information and Document Resource Service

Major Federal and Provincial Health Care Inquiries:  A Select Bibliography

Specific Reading on Health Inquiries:

Angus, Douglas.  Review of Significant Health Care Commissions and Task Forces in Canada Since 1983-84.  Ottawa:  Canadian Medical Association and Canadian Nurses Association, 1991.

Bickerton, James.  “Reforming Health Care Governance:  The Case of Nova Scotia.”  Journal of Canadian Studies, 34(2), 1999, pp.159-190.

Bird, Richard M. and Roderick D. Fraser. Commentaries on the Hall Report.  Discussion Paper Series, Toronto: Ontario Economic Council, 1981.

Chodos, Howard.  Quebec’s Health Review (The Clair Commission).  PRB 00-37E, Ottawa:  2001.

Cohn, Daniel.  “No Place to Hide:  The Unfeasibility of Using an Independent Expert Commission as a Blame-Avoidance Mechanism in Westminster Polities – The Case of the Ontario Health Services Restructuring Commission.”  Canadian Public Administration, 44(1), 2001, pp. 26-46.

Commissions Share Some Ideas, Differ on Others:  Comparing the Fyke, Clair and Mazankowski Reports.”  Links:  The Newsletter of the Canadian Health Services Research Foundation, 5(1), Spring 2002, pp. 6-7.

Fooks, Cathy and Steven Lewis.  Romanow and Beyond:  A Primer on Health Reform Issues in Canada.  Ottawa:  Canadian Policy Research Networks, November 2002.

Gelber, Sylva.  “The Path to Health Insurance.”  Canadian Public Administration, 9, June 1966, pp. 211-220.

Hastings, J. E. F.  "Federal-Provincial Insurance for Hospital and Physicians Care.”  International Journal of Health Services, 1(4), 1971, pp. 398-414.

Hurley, Jeremiah, Jonathan Lomas and Vandna Bhatia.  “When Tinkering is Not Enough:  Provincial Reform to Manage Health Care Resources.” Canadian Public Administration, 37(3), 1994, pp. 490-514.

McLintock, Peter.  A Health Plan for Canada:  A Study of the Hall Commission Report. Winnipeg Free Press Pamphlet No. 79, Winnipeg:  Winnipeg Free Press, 1964.

Mhatre, Sharmila and Raisa Deber.  “From Equal Access to Health Care to Equitable Access to Health:  A Review of Canadian Provincial Health Commissions and Reports.”  International Journal of Health Services, 22(4), 1992, pp. 645-668.

Miller Chenier, Nancy.  Reshaping Canada's Health Care System:  Reports from a Senate Committee and a Royal Commission.  PRB 02-24E, Ottawa: 2002.

Smith, Margaret.  Report of the Premier’s Advisory Council on Health (Alberta) – An Overview.  PRB 01-33E, Ottawa:  2002.

Taylor, Malcolm.  “Government Planning:  The Federal-Provincial Health Survey Reports.”  Canadian Journal of Economics and Political Science, 19(4), November 1953, pp. 501-510.


 

 

Selected Reports from 1940s to 1960s Inquiries

Advisory Committee on Health Insurance.  Report.  Ottawa:  1943.
Chair:  John J. Heagerty

Health Services Survey Commission.  Report.  Regina:  1944.
Chair:  Henry Ernest Sigerist

Health Survey Committee.  Report.  3 vols.  Toronto:  1952.
Chair:  George D. Davis

Royal Commission on Health Services.  Report.  2 vols.  Ottawa:  Queen’s Printer, 1964-1965.
Chair:  Emmett Hall

Royal Commission on Health.  Report. 2 vols.  St. John’s:  1966.
Chair:  W. Russell Brain

Commission of Inquiry on Health and Social Welfare.  Report.  7 vols.  Québec: 1967-1971.
Chairs:  Claude Castonguay, 1966 to 1970, replaced by Gerald Nepveu


 

 

 

 

Selected Reports from 1970s to 1980s Inquiries

Committee on the Costs of Health Services.  Task Force Reports on the Cost of Health Services in Canada.  Ottawa:  Queen’s Printer, 1970.
Chair:  Joseph W. Willard, Acting Deputy Minister of National Health; Chairs and Co-chairs of seven task forces: various individuals

Committee on the Healing Arts.  Report.  4 vols.  Toronto:  1970.
Chair:  Ian R. Dowie

Health Security for British Columbians:  Report to the Minister of Health.  2 vols.  Victoria:  1973.
Chair:  Richard G. Foulkes

Health Services Review ’79.  Canada’s National-Provincial Health Program for the 1980's:  A Commitment for Renewal.  Ottawa:  Health and Welfare, 1980.
Special Commissioner:  Emmett M. Hall

Legislative Select Committee on Health.  Report.  Halifax:  1984.
Chair:  R. C. D. Stewart

Task Force on the Use and Provision of Medical Services.  Report.  Toronto:  1987.
Chair:  Graham W. S. Scott

Commission d'enquête sur les services de santé et les services sociaux.  Rapport.  Québec:  1988.
Chair:  Jean Rochon

Premier's Commission on Future Health Care for Albertans.  The Rainbow Report:  Our Vision for Health.  4 vols.  Edmonton:  1989.
Chair:  Louis D. Hyndman

Commission on Selected Health Care Programs.  Report.  Fredericton:  1989.
Co-chairs:  E. Neil McKelvey and Bernadette Lévesque


Selected Reports from 1990s to 2000s Inquiries

Commission on Directions in Health Care.  Future Directions for Health Care in Saskatchewan.  Regina:  1990.
Chairman:  R. G. Murray

Royal Commission on Health Care and Costs.  Closer to Home.  3 vols.  Victoria:  1991.
Chair:  Peter Seaton

National Forum on Health.  Canada Health Action:  Building on the Legacy.  (vol. 1 and vol. 2).  Ottawa:  Public Works and Government Services, 1997.
Chair:  Jean Chrétien, Prime Minister of Canada; Chairs of four working groups: various individuals

Senate.  Standing Senate Committee on Social Affairs, Science and Technology.  The Health of Canadians - The Federal Role.  6 vols.  Ottawa:  2001-2002.
Chair:  Michael Kirby

Premier’s Advisory Council on Health for Alberta.  A Framework for Reform.  2 vols.  Edmonton:  2001.
Chair:  Donald Mazankowski

Legislative Select Standing Committee on Health.  Patients First:  Renewal and Reform of British Columbia's Health Care System.  Victoria:  2001.
Chair:  Valerie Roddick

Legislative Select Committee on Health Care.  Working Together for Wellness:  A Wellness Strategy for New Brunswick.  Fredericton:  2001.
Chair:  Madeleine Dubé

Commission d’étude sur les services de santé et les services sociaux.  Emerging Solutions:  Report and Recommendations.  Québec:  2001.
Chair:  Michel Clair

Commission on Medicare.  Caring for Medicare:  Sustaining a Quality System.  Regina:  2001.
Chair:  Kenneth J. Fyke

Standing Committee on Health Care.  Report Respecting the Final Report of the Commission on Medicare.  Regina:  2001.
Chair:  Judy Junor


General Reading:

Duffin, Jacalyn and Leslie A. Falk.  “Sigerist in Saskatchewan:  The Quest for Balance in Social and Technical Medicine.”  Bulletin of the History of Medicine 70.4 (1996), pp. 658-683.

Jenson, Jane.  “Commissioning Ideas:  Representation and Royal Commissions.” In How Ottawa Spends 1994-95:  Making Change, ed. Susan Phillips.  Ottawa:  Carleton University Press, 1996, pp. 39-69.

Maioni, Antonia.  Public Health Insurance through History.   Web site of the McGill Institute for the Study of Canada.

Philippon, Donald and Sheila Wasylyshyn.  “Health-care Reform in Alberta.”  Canadian Public Administration, 39(1), 1996, pp. 70-84.

Pross, Paul, Innis Christie, and John Yogis, eds.  Commissions of Inquiry.  Toronto:  Carswell, 1990.

Renard, Marc.  “Quebec:  The Adventures of a Narcissistic State.”  In The End of an Illusion:  The Future of Health Policy in Western Industrialized Nations, ed. Jean de Kerasdoue et al. Berkeley:  University of California Press, 1984, pp. 167-205.


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