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:
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.
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
Refining Medicare: The Maturing Years
Revising Medicare: The Modifying Years
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 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.
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.
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.
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.
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.
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.
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
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.