A Medicare@50 blog post by:
Scott A. Wolfe (@ScottAWolfe)
Executive Director – Canadian Association of Community Health Centres

As the Premiers of Canada’s thirteen provinces and territories get set to meet in Niagara-on-the-Lake, Ontario from July 24-26, Canadians will be watching to see what comes of these talks, particularly in the context of a federal government that continues to back away from its leadership role and meaningful collaboration with the provinces and territories.

The significance of this gulf within Canadian politics is perhaps nowhere greater than with respect to health care, an issue that Canadians continue to identify as a top priority, yet for which the federal government has all but washed its hands in recent years. The fact that the federal health ministry — Health Canada — garnered barely a mention in media reports of last week’s federal Cabinet shuffle underscores how far the federal government has let this file slip among its priorities, despite its continued importance to Canadians.

The gutting of federal health care services for refugees, RCMP and veterans’ long-term care, as well as the recent axing of the Health Council of Canada — an agency established to monitor and report to Canadians on the status of our health system — are proof positive of this federal retreat from health care.

Astride this abysmal state of affairs, health and healthcare agencies across Canada, including the Canadian Association of Community Health Centres (CACHC), continue to stand united in their call for the federal government to take its seat at the healthcare table and to collaborate with the provinces and territories to bring greater harmony, innovation and economies of scale to health services across the country. This includes a call for the federal government to sit down with the provinces and territories to negotiate a renewed 10-year Health Accord once the current accord expires in 2014. So far, this call from Canadians remains unheeded.

The need for a renewed Health Accord that would provide a framework for inter-provincial/territorial knowledge exchange and collaboration; that would set goals and targets for health system improvements across the country; that would enable funding to be attached to those key goals and targets; and that would facilitate major cost-savings to Canadians through opportunities for bulk purchase of healthcare related goods, is abundantly clear and would be evident to any first-year business, economics or public administration student. Yet, for reasons around which we are left to speculate, the federal government appears as though it prefers to perpetuate a status quo of thirteen provinces and territories acting without any federal government presence, steering in thirteen different directions. The call for a federal presence and a renewed Health Accord find their latest expression in a Shadow Health Summit organized to coincide with the Council of the Federation’s meeting in Niagara-on-the-Lake this week.

To their credit, the Council of the Federation and its constituent Premiers, Ministers and working groups have taken some important steps into this “black hole” of federal leadership, searching for areas around which the provinces and territories can begin finding accord and common action, absent the federal government. Healthcare agencies across Canada, including CACHC, continue to work with them to build a shared Canadian agenda and objectives in health care, even if the Government of Canada, ironically, does not see itself as being part of important Canadian projects such as this. Most recently, the single largest grouping of Canadian healthcare agencies, including CACHC, the Canadian Nurses Association, Canadian Medical Association and over 40 others, all united through the Health Action Lobby (HEAL), communicated to the Premiers key recommendations for inter-provincial collaboration to improve health care across Canada.

It is worth mentioning that among these recommendations is a call for the provinces and territories to collaborate in expanding access for Canadians to “patient-centered, community-based primary care, delivered by inter-professional teams working collaboratively to their full scopes”. This is a goal that CACHC continues to pursue through its mission of supporting Community Health Centres — organizations that exemplify patient-centred (or, people-centred) primary health care as defined by the World Health Organization, and delivered through inter-professional teams.

Upon closer inspection, however, the actual state of Community Health Centres (CHCs) across Canada provides an excellent case study of the need not only for collaboration among the provinces and territories, but for a strong federal role in health care, and the negotiation of a 2014 Health Accord.

It would surprise most Canadians, as it would no doubt many people working within CHCs across Canada, to learn that there are currently over 700 CHCs across the country. These are local organizations that meet the definition of “Community Health Centre”, providing team-based primary health care that includes clinical primary care, health promotion and community health and development programs. Nomenclature is one reason why these 700-plus CHCs seem to be “hiding in plain sight” across Canada. They are sometimes known specifically as “community health centres”, while at other times they are known in different jurisdictions as “cooperative community clinics”, “family care clinics”, “centres locaux de services communautaires” (in Quebec), “aboriginal health access centres”, “community family health teams” and other names.

These existing CHCs, along with an additional 130-plus CHCs that have recently been announced for implementation in Alberta (termed family care clinics), constitute a significant part of Canada’s primary health care infrastructure. However, there is no federal or inter-provincial/territorial funding, planning or policy guidance for CHCs, and there are major policy obstacles within the different provinces and territories that hinder CHCs from achieving their full potential for Canadians. Contrast this with the United States, where federal legislation helps support and harmonize a vast network of over 9000 Community Health Centre locations that provide high-quality primary health care services to over 22 million Americans, regardless of their ability to pay (a beacon of hope and potential within the US’s otherwise troubled health system).

The lack of either a federal or inter-provincial vision, planning and funding for Community Health Centres in Canada is most conspicuous in the differing nomenclature (as described above) that provincial and territorial governments have used to brand these community-based primary health care services in their respective jurisdictions. Ironically, many of these governments are attempting to shift their health systems toward the people-centred Community Health Centre model of care, at least for segments of their population, but with little to no collaboration and learning across jurisdictions.

The impact of this lack of coherence and collaboration among provinces/territories around CHCs and community-based primary health care, to say nothing of the absence of the federal government, also manifests in the wide variation among CHCs across the country. The vast range in funding levels, healthcare provider agreements, physical infrastructure and other dimensions of these CHCs across the country defies easy description, other than to say that there is a preponderance of major challenges. These challenges differ in scope from one region to the next.

For its part, the Canadian Association of Community Health Centres is working hard to help bridge these divides and to better document the wide range of organizational dynamics among CHCs across Canada. The first ever cross-Canada CHCs Organizational Survey, launched in July 2013, will enable the association and CHCs across the country to take a major step forward in this respect. 

CACHC”s member supports and gatherings, such as the upcoming Medicare@50: Our Healthy Future and the Role of Community Health Centres provide yet more opportunities for CHCs, researchers and policy makers to speak with and learn from one another in the context of this patchwork of provincial, territorial and federal arrangements around primary health care.

Still, there is only so far an association can carry a movement for increased harmonization and support among 700-plus individual health organizations, across multiples jurisdictions, when what is fundamentally required is a shift in perspective and action among the federal, provincial and territories governments toward cross-jurisdictional learning, collaboration and planning.

Canada’s baseline of roughly 850 Community Health Centres (including those soon forthcoming in Alberta) constitutes what could, with effective policy and planning support from the federal, provincial and territorial governments, become a true “primary health care system” for Canadians. This would be a primary health care system that could become the envy of the world, as was Quebec’s provincial network of CHCs (CLSCs) when they first took root in the the 1970s and 1980s.

The essential ingredients of such a pan-Canadian system of CHCs and community-based primary health care are already there, ready for the shaping. Policy and planning support, coupled with a re-orientation of financial resources already allocated within federal and provincial health budgets, could bring this system into reality. However, this cannot and will not happen without the political will among the different levels of government needed to make it so. In the meantime, Canadians suffer from the missed opportunity that lies therein, unable to access the primary health services they need whilst the potential solution lies in plain sight.

This week’s meeting of the Council of the Federation provides an important opportunity to see whether this political will and appetite exists among the provinces and territories. Commitment will also need to emerge from the federal government since a 2014 Health Accord would provide the necessary framework, goals and indicators that would unite provinces and territories in a common project of building a true pan-Canadian system of CHCs and community-based primary health care.

This is what we might call “low-hanging fruit”, ready for the picking. The potential is great. Political will is the missing ingredient. Will we witness the emergence of this political will in the near future? Canadians from coast to coast are watching.