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Livio Di Matteo: How can we spend so much on health, yet still fail so badly?

Commentary

The pandemic has highlighted a long list of issues in Canadian health care.

From long-term care, vaccine production and distribution, ICU and general bed capacity in hospitals, public health and health human resources, we’re certainly not short of areas to improve.

The immediate response in 2020 was an increase in total health spending as taken from assorted announced federal and provincial measures — mainly federal — totalling $44 billion though much of it remains unspent.

As well, the provinces, who are responsible for the delivery of publicly funded health care services in Canada and who account for nearly 70 percent of health spending, have also made the call for more long-term resources from the federal government. That would come in the form of an increase in the Canada Health Transfer of $28 billion annually and would come on top of the current transfer of approximately $42 billion which has been growing at about three percent per year.

When it comes to health care, much of the debate will be on how prepared Canada was particularly in the area of public health.

Compared to other countries, was Canada’s medical system well enough equipped to deal with the increased demands of the pandemic?  Nowhere has the debate been more contentious than in the area of public health given that the pandemic response illustrated weakness in our efforts ranging from having plans that were not followed to lack of critical supplies of personal protective equipment at both the federal and provincial levels.

Naturally, there will be a view that the sector requires new investment to deal with future pandemics.

In the wake of the SARS outbreak in 2004 which was supposed to serve as a wake-up call about the need for future pandemic preparedness, both federal and provincial public health spending grew substantially, according to numbers compiled by the CIHI National Health Expenditure Estimates. Indeed, it was one of the fastest growing health spending categories of the 21st century in Canada.

Between 2004 and 2019, real per capita spending (in 2019 dollars) on public health and associated preparedness rose from $210 to $305 by provincial-territorial governments and $50 to $71 dollars federally — respective increases of 45 and 42 percent.  

By way of comparison, at the provincial-territorial government level, real per capita spending on hospitals grew by only 12 percent, drugs by 10 percent, other institutions (including long-term care) by 22 percent and physicians at 41 percent. On an annualized basis, real per capita provincial-territorial government public health spending grew at 3 percent compared to less than one percent for hospitals and drugs, 2.8 percent for physicians, 1.5 percent for other institutions and 1.8 percent for overall health spending. 

However, the provinces are a heterogeneous bunch when it comes to health spending with substantial differences even when it comes to public health spending and public health outcomes.  For example, between 2004 and 2019, Ontario’s real per capita public health spending in 2019 dollars grew from $217 to $383, an increase of 77 percent and the second largest increase of all nine of its CIHI expenditure categories. By comparison, its hospitals grew barely one percent, physicians 37 percent and drugs 16 percent. Meanwhile, British Columbia — which has done somewhat better than Ontario in the fight against COVID-19 — over the same period saw its real per capita public health spending grow from $228 to $347, which is an increase of 52 percent as opposed to Ontario’s 77 percent.  True, B.C. started from a higher base, but Ontario has more than caught up. 

The more crucial criticism with respect to public health spending really should be about the value for money

The claim that somehow the public health sector was financially short-changed in the years leading up to the COVID-19 pandemic does not measure up.  

While spending growth rates at the provincial level slowed after the Great Recession, they were even worse for the hospital sector which actually saw a slight decline in real per capita spending after 2009.

The more crucial criticism with respect to public health spending really should be about the value for money.  Increases in public health spending after SARS seemed to have been accompanied by substantial planning exercises for future pandemics but weak ability to implement effective action, the erosion of stockpiles of personal protective equipment, the lack of investment in modern data processing and contact tracing, as well as the eventual deactivation of our pandemic intelligence gathering apparatus at the federal level.

As for increasing resources to the health sector, if anything the state of the hospital sector requires review. Provincial government hospital spending in Canada has seen restrained growth for nearly two decades and the big concern during the pandemic was that surges in Covid-19 cases would overwhelm our capacity. Indeed, when international comparisons are made, of the 37 OECD countries reported in the OECD 2020 Health Statistics, Canada ranks 31st in terms of hospital beds per thousand patients. 

The cost of this especially during the first wave of the pandemic was the cancellation of numerous appointments and surgeries. As reported by the CIHI in its 2020 NHEX Report, from March to June 2020, overall surgery numbers fell 47% compared with the same period in 2019, representing about 335,000 fewer surgeries — meaning less money spent on health.

In the United States, overall health spending appears to have dropped slightly in 2020 for the first time in its recorded history. One suspects a similar story may emerge for Canada once the dust settles and actual health spending rather than the announcements for 2020 is fully tallied. It would be a somewhat embarrassing prospect for governments asking for more health dollars.

We appear to have dropped the ball on public health and our hospital sector was hard pressed to deal with the surge in cases without cancelling other activities. Yet, the same OECD statistics however show that we are 7th out of 37 when it comes to health spending as a share of GDP.

Again, this goes to show that the key issue is not about how much we are spending on health but how and where we are spending it.  Until we can figure out how it is that we are able to spend so much and yet still were caught with our pants down when it came to the ability of our health system to cope, all the transfer increases in the world will do nothing to improve the Canadian health care system.

Veronica Green: Gender analysis should go beyond the prototypical Liberal woman

Commentary

There is a conventional narrative of a “professional woman” that has informed the Canadian definition of success and in turn shaped most of the current Liberal government’s female-focused public policy.

It goes like this: a young woman graduates university, climbs the professional ladder in a relatively short period of time, pauses briefly to have children in her mid-20s, achieves professional success just shy of 50, and retires at about 70-years-old. She is of course in a committed relationship, most likely to man, and lives a 15-minute drive from her parents.

She certainly exists and she may align with the Liberal worldview, but not all women fit this mould and not all women are Liberal.

In 2015, when Justin Trudeau stood with 15 men and 15 women on either side of him to reveal his gender equal cabinet, I was encouraged. But in the past six years, my feminist credo, and that of my prime minister, has been challenged. We have both been confronted by the realities of what it means to be a woman in the workplace.

Trudeau’s government has used a gender-based analysis plus (GBA+) framework in policymaking, which assesses how women, men, and non-binary people experience programs, policies, and initiatives. GBA+ is sensible — policymakers ought to consider the people they are making the policy for — but the problem is that women (and men for that matter) are not a monolithic group.

For example, the government’s promised $30 billion national daycare system is admirable in its approach, but the policy does not address the many women who do shift work, have multiple jobs, or simply work long hours.

Following COVID-19, policymakers can no longer afford to apply GBA+ to individual policymaking and be satisfied that they have checked the “woman” box. To achieve a #FeministRecovery and improve gender-equality in the workplace long-term, the Trudeau government needs to make a genuine commitment to rooting their policy-making in the real-world experiences of different Canadian women. 

It would be disappointing if the pro-female progress fell victim to the ‘spend now, cut later’ doctrine.

There are a couple of examples in Budget 2021 where the Liberals almost get this right.

First is the proposal that Crown corporations be required to implement gender and diversity reporting starting in 2022. The disclosure of public data and key metrics can hold companies accountable and enable young women to make informed decisions about where they want to work. Recent public reporting of gender metrics has led to real culture change at one major Toronto law firm.

This transparency in the workplace should be non-negotiable and the mandate should extend to the private sector. For example, the government plans to spend $80 million over three years to help teach kids to code. I like to imagine that one day my future daughter will be able to code — but it would be even better if she could look forward to employment with confidence, knowing her prospective employer has historically promoted both men and women at an equal clip. 

The second area of achievement is procurement. To increase diversity in procurement, Budget 2021 proposes to leverage supplier diversity opportunities through domestic procurement, running competitions from equity-deserving groups. Mandating that women-owned companies be part of Canada’s procurement process or that companies seeking government RFPs achieve and report their workplace’s gender-diversity are two ways the government can build a more inclusive economy by design. 

While both programs are not shout-from-the-rooftop “Re-elect me!” policies, they are meaningful ways to address the realities that professional women face. There is little accountability or incentive for companies to address gender inequality and the companies women own are least likely to receive government contracts. These policies have potential to address systemic gender inequalities in the workplace and to make a real difference for women long-term. 

Increasingly, my peers and I look to our employers to support our life decisions, seeking work at companies and organizations that purport to not only have generous maternity and paternity leaves, but that also offer childcare support and fertility treatments such as egg-freezing as part of corporate benefit plans. Allowing women to plan and have “control” over the biological clock empowers them to have children without having to take a foot off the professional ladder.

There is no doubt the Liberal government continues to own the feminist narrative in comparison to their political counterparts. In Budget 2021, supports for women extended beyond the workplace and include important funding for the Women Entrepreneurship Strategy, a National Institute for Women’s Health Research, access to reproductive health care information and services, and funding for a National Action Plan to End Gender-Based Violence. Neatly, each of these policies favour women most significantly on the GBA+summary chart.

There is over $100-billion in new spending in Budget 2021 and Trudeau’s promise to run deficits is one he has kept. It would be disappointing if the prime minister underestimated the political cost of borrowing and the pro-female progress made in the budget fell victim to the “spend now, cut later” doctrine.

That said, if an opposition party, like Erin O’Toole’s Conservatives, moved away from conventional narratives to create policies that acknowledge and empower women to make choices that work for their own professional trajectories — reordering conventional rungs or hitting pause on traditional trajectories — there might just be a path to the ever-needed women’s vote.

Letting women know that the government has included gender equality by design and acknowledging new realities in policy is paramount. Canada’s future prosperity and competitiveness depends on encouraging young women to redefine the arc of a successful career and enabling them to take control of their professional trajectory, whether they conform to the prototypical Liberal image or not.