Health Committee on Feb. 24th, 2009

[The Chair, Conservative, Joy Smith]

Good afternoon, ladies and gentlemen. I welcome our guests to the committee today.

Before we start, I want to very quickly bring one thing to the committee. Last time we had an extra member from the NDP party who sat down and joined in the questioning. There are rules, and I only want to make you aware of the rules. After the committee meeting yesterday, a couple of people talked to me about the participation of other members in committee meetings. This is what everybody has to be aware of.

In addition to regular committee members, the Standing Orders also provide for associate members. Associate members are eligible to be named to subcommittees and may be designated to act as substitutes for regular members who are unable to attend committee meetings. Of course, that's when we sign the form and they sit in.

Any member of the House may attend committee meetings, question witnesses, and participate in the committee's public proceedings unless the House or the committee concerned orders otherwise, which means it's at the committee's discretion. In other words, someone may sit in, at the discretion of the committee, unless someone objects. In most committees, there is an objection if someone else sits in without permission from the committee itself. These members may move motions, vote, or be part of a quorum only when acting as an officially designated substitute for a permanent committee member.

I only want to make you aware of the rules. We'll be watching to make sure that everybody abides by the rules.

I would now like to welcome all the witnesses today who are coming to join us. We have witnesses from the Office of the Auditor General of Canada. Mr. Neil Maxwell is the assistant auditor general. I welcome you, Mr. Maxwell. It's great to have you here today. Glenn Wheeler, principal, thank you as well for being here. Louise Dubé, principal, I'm so glad you could join us.

From the Department of Health, we also have Karen Dodds, assistant deputy minister of the strategic policy branch. Welcome, Karen. Janice Dyer is the director general of applied research and analysis, strategic policy branch.

We also have the Department of Finance represented here today. Monika Bertrand is the chief, federal-provincial relations division, federal-provincial relations and social policy branch. It's a long title for one person.

I want to welcome you all. We look forward to your presentations today.

The Auditor General's office, the Department of Health, and the Department of Finance each have seven minutes to make a presentation. Following that, we will then go into the rounds of questioning.

Mr. Maxwell, would you be so kind as to begin. Thank you.

[Neil Maxwell, Assistant Auditor General, Office of the Auditor General of Canada]

Madam Chair, thank you for this opportunity to present the results of two chapters in our December 2008 report, a study on federal transfers to the provinces and territories and our audit of Health Canada's reporting on health indicators. With me today, as the chair has mentioned, is Glenn Wheeler, the principal responsible for those two chapters, and Louise Dubé, the principal responsible for our Health Canada audits.

Federal transfers to the provinces and territories make up a significant portion of the federal government's annual spending. They are a major source of funds for services provided to Canadians in areas such as health, post-secondary education, and social assistance. In the 2006-07 fiscal year, the most recent year for which complete information was available to us during the study examination period, these transfers amounted to about $50 billion or just under 23% of federal spending.

Our study looks at the three main types of transfer payments made by the federal government to the provinces and territories. We undertook this study to answer questions that parliamentarians have raised about federal transfers and our mandate to audit. Because this is a study and not an audit, it is descriptive and does not include recommendations.

In this work, we examined the three main mechanisms the federal government uses to transfer funds to the provinces and territories. The first and largest includes four major transfers managed by Finance Canada, including the Canada health and social transfer. The second mechanism involves the transfers of funds by individual federal departments to support specific programs areas. Finally, the third mechanism involves the federal government's transfers of funds to the provinces and territories using trusts managed by Finance Canada.

We found that the nature and extent of conditions attached to federal transfers to the provinces and territories varies significantly. While some transfers have specific conditions that recipients must meet, often including reporting to the federal government on the use of the transferred funds, others are unconditional. In all cases, the federal government is accountable for its decision to use transfers with or without conditions as the best policy choice available in the circumstances. However, as auditors, we recognize that decisions on whether, and to what extent, conditions are attached to transfers are policy decisions, often involving sensitive federal, provincial and territorial negotiations. In our work, we do not question policy decisions.

A significant change in transfer mechanisms used by the federal government was its introduction of trusts in 1999. Since then, 23 trusts have been established to transfer almost $27 billion to the provinces and territories. Transfers of this type are earmarked in public announcements by the federal government for specific purposes (for example, patient wait times guarantees), but there are no conditions that legally obligate provinces and territories to spend the funds for the announced purposes or to report subsequently on that spending to the federal government. As an alternative, federal officials told us that the government has opted in recent trusts to require provinces and territories to publicly announce how they intend to use the funds, on the assumption that their legislative assemblies and citizens will hold them to account for these commitments.

As mentioned, our December report also contains a chapter on our audit of Health Canada's reporting of health indicators.

The Government of Canada and provincial and territorial governments reached a series of agreements to strengthen and renew Canada's publicly funded health care system. The 2000 health communiqué, the 2003 first ministers accord on health care renewal, and the 2004 first ministers 10-year plan to strengthen health care called for governments to demonstrate accountability through comprehensive and regular reporting to Canadians.

One of the key commitments was for the federal, provincial, and territorial governments to report to the public on comparable health indicators. First ministers saw health care reporting as an important vehicle for enhancing transparency and accountability. All jurisdictions subsequently agreed on a comparable set of health indicators to report on. Public reporting by governments promotes accountability in a number of ways, for example, by allowing Canadians to see the extent to which governments are attaining their goals and objectives.

On behalf of the federal government, Health Canada has responded to commitments in the agreements on health indicator reporting by preparing Healthy Canadians: A Federal Report on Comparable Health Indicators. This report is published every two years, with additions in 2002, 2004, 2006 and one upcoming for 2008.

In our audit, we examined whether Health Canada's reporting on health indicators met the commitments made in the first ministers' health agreements. We also examined whether its reporting has improved over time.

We found that Health Canada met specific health indicator reporting obligations that were required by the agreements—including identifying common indicators for reporting with its provincial and territorial counterparts. The department has produced a health indicators report every two years.

Although Health Canada met the specific commitments to report on health indicators, The Healthy Canadians reports do not fulfill the broader intent of the agreements—that is to provide the information Canadians need on the progress of health care renewal. While the reports provide indicators, such as self-reported wait times for diagnostic services, they do not provide sufficient information to help readers interpret them. There is no discussion of what the indicators say about progress and health renewal. Without interpretation, their ability to inform Canadians is limited.

We reviewed each edition of Healthy Canadians to see if it had improved over time. We found the presentation of the information in all three editions was essentially the same, with some modest improvements, despite the fact that Health Canada had received feedback through consultations indicating that the information needs were not being fully met through the reports.

Madam Chair, Health Canada agreed with our recommendations and committed to a number of improvements for the 2008 edition, with the remaining action to follow, including a thorough review of its role and its approach to health indicator reporting in 2009. Health Canada needs to clarify its role relative to other health indicator reports produced by the Canadian Institute for Health Information, Statistics Canada, and the chief public health officer. Your committee may wish to ask Health Canada what improvements have been made in the 2008 edition and what plans are in place for subsequent improvement.

Madam Chair, that concludes my opening statement, and we would be very pleased to answer your committee's questions.

[The Chair, Conservative, Joy Smith]

Thank you very much, Mr. Maxwell. We look forward to inquiring about some things in a few moments.

We'll now hear from Karen Dodds, assistant deputy minister.

[Dr. Karen Dodds, Assistant Deputy Minister, Strategic Policy Branch, Department of Health]

Thank you. Madam Chair, members, I'm very pleased to have the opportunity to be here with you this afternoon.

I am here to talk about two important aspects of the Auditor General's report—federal funding and reporting, as related to health care.

The federal government has demonstrated its commitment to health care by increasing transfers to provinces and territories, including growing support for health.

I'd like to set the context for my remarks by noting that we've had a long and productive relationship with the Auditor General. We invited the Office of the Auditor General to audit the first release of Healthy Canadians in 2002, and then again in 2004 and in 2006. In 2008 the Office of the Auditor General decided a more overarching review of health information reporting would be useful. We're pleased that the Auditor General has undertaken this task and has provided to us the very useful feedback that they did in their report.

To clarify, Healthy Canadians is a federal report to all Canadians, on comparable health indicators at a national level.

Each province and territory is committed, in the health accords, to releasing a separate indicator report covering their own jurisdiction, to their own citizens.

The Auditor General has indicated that Health Canada has met the specific health indicator reporting obligations of the accords. However, it noted there are ways that Healthy Canadians can be improved, and we've taken time to rethink some of those improvements for its next release. In Healthy Canadians 2008, to be released next month, we've taken the Auditor General's recommendations to heart and have made some significant improvements. We have expanded the report's scope by adding 19 new indicators drawn from a list of 70 comparable indicators approved by federal, provincial, and territorial health ministers. This brings the total number of indicators in Healthy Canadians to 37.

For example, on access we've added the proportion of the population that reports having a regular family doctor. We've added wait times for surgery and specialists.

On quality we have added, for example, mortality rate for stroke; mortality rate and readmission rate for acute myocardial infarction.

On health status and wellness, we've added, for example, life expectancy; infant mortality; low birth weight; and mortality and incidence rates for lung, prostate, breast, and colorectal cancer. We've also added more in-depth interpretation of the data by clearly relating it to accord commitments.

We will have a more proactive communications approach with a media release, posting on the Health Canada website, notification of health professionals, and highlighting of the report in announcements and speeches. For Healthy Canadians 2010 and beyond, we will be providing more data on first nations and Inuit health from the Aboriginal Peoples Survey. We're also working with other federal departments to determine how health data can be collected and reported for federal population groups, including the military and RCMP staff, veterans, refugees and some immigrants, and federal prisoners.

Our minister is very interested in the health status and well-being of Canadians. She is well aware of the indicators and statistics surrounding life expectancy, infant mortality and the prevalence of diabetes in the population. She is very supportive of improvements in reporting on health and the health care system.

So reporting to Canadians is, and will be, very important, and we'll do our utmost to go further in comparable indicator reporting.

We're here to answer any questions you may have. We look forward to profiting from the Auditor General's observations and the discussion this afternoon.

[The Chair, Conservative, Joy Smith]

Thank you very much, Karen, for those insightful comments.

We'll begin with our questions now. The first round is seven minutes each.

We'll start with Ms. Murray.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Thank you.

I'm taken aback by the idea that the 2008 report is due in two days and we're spending two hours on the 2006 report. I hope I can make some questions and comments that will still be useful.

My background is having sat at a cabinet table for four years, wrestling with health spending that was ballooning out of control and gobbling up the budgets of other important ministries, like environment. At the same time, I have lots of constituents who are very concerned about health care and value for money and how we can avoid this continuing to balloon while maintaining a public health care system. I think indicators, measures, and goals and targets are critical to improving things. Just by measuring things, you improve them. There's research on continuous quality improvement.

A quick question I have is to the assistant deputy minister, Ms. Dodds. Given the purpose of the 2006 report—to provide information on comparable health indicators to help federal, provincial, and territorial jurisdictions and health care providers monitor trends and progress toward improving the health of Canadians—do you believe this report does that?

[Dr. Karen Dodds]

As we've noted, Healthy Canadians is one of the ways in which we fulfill our reporting obligations under the accords.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

So that's a yes? You feel this actually helps with that goal?

[Dr. Karen Dodds]

There is an agreement in the accords that the comparable indicators would be common and agreed upon by federal, provincial, and territorial ministers of health. That 2006 report has 17; for 2008, we've more than doubled it, including another 19.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

I appreciate that you've responded to the Auditor General's comments, which I thought were very tactful, considering the gap between how indicators could help us improve our health care delivery and what I thought this delivered in terms of usable information. The Auditor General's talk, in terms of delivery, page 8 or 9--no documentation to give you the guidance as to what to do, not clear what the report's trying to do, doesn't tell a performance story, has not improved over time. The recommendation is that Health Canada should review its role and approach to health indicator reporting. That's relatively pointed.

Do you believe, Ms. Dodds, that your 2008 report is a substantive change in approach, or is it an incremental improvement on what was in the 2006 report?

[Dr. Karen Dodds]

As the Auditor General noted in her report, and as we've discussed, we have not just the report Healthy Canadians in order to report on the health accord. The intent of Healthy Canadians has been, and has continued to be to this day, to report on the comparable indicators that were agreed upon by federal, provincial, and territorial ministers. We've added more and we've added interpretation this year. But beyond that, there are many other ways of reporting. The Auditor General noted, and we agreed, that it's difficult to pull everything together. We report every year to Parliament in our report on plans and priorities. We report in the departmental performance report and in our main estimates, etc., on different bits.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Yes, but I'm focusing on this one. But thank you for the context.

I have another question. What does it cost to produce this report, including all the staff time and salary and benefits that go into it?

[Dr. Karen Dodds]

I'm just checking with my colleague, who has more direct responsibility.

[The Chair, Conservative, Joy Smith]

Are you going to speak to that, Ms. Dodds, or would Ms. Dyer like to speak to it?

Ms. Dyer, do you want to comment on that, please?

[Janice Dyer, Director General, Applied Research and Analysis Directorate, Strategic Policy Branch, Department of Health]

In direct costs, we spend about $53,000 a year to produce the book. We have three people who work on it. The staff time for three people is roughly in the neighbourhood of $150,000 a year. That's about what we spend.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

For two years?

[Janice Dyer]

We do it only every two years, so yes, we spend that amount of money divided by two. You're right.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

As a public citizen reading this to figure out how we're doing and what we need to do, I would say it's not hugely helpful for actually providing health care the opportunity to monitor trends, etc. It's not helpful at all. I'm not trying to be critical here. You're attempting to do what a collection of provinces indicated would happen, but it just seems to be window dressing to me. I'm wondering if it is inherent in Health Canada's mandate and the politicization of potential outcomes that....

Maybe this is for Mr. Maxwell. Do you believe it's possible for Health Canada as an organization to meaningfully put forward indicators and trends that can inform the professional public and health care providers so we can improve how we deliver health care?

[The Chair, Conservative, Joy Smith]

Just to give you some time, Ms. Dodds, could you try to answer some of those inquiries?

[Dr. Karen Dodds]

Thanks very much.

Again, when you go beyond comparable indicators to trends and progress about health care, Health Canada provides up to $10 million every year to the Health Council of Canada. In the accord, the Health Council of Canada was mandated to do the overall reporting on trends and progress from the health accords. That's different and separate from simply the comparable indicator reporting.

We also provide $81 million every year to the Canadian Institute for Health Information. As well, we provide some funds to Statistics Canada. Those two organizations are very important in putting together the data which we then collect and put into Healthy Canadians.

What you see going into Healthy Canadians is just one small part focused on comparable indicators. In terms of the money, as my colleague said, it's three professionals versus several hundred at the Canadian Institute for Health Information and the large staff at Statistics Canada and their health program.

[The Chair, Conservative, Joy Smith]

Thank you, Ms. Dodds.

Monsieur Malo.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

Thank you, Madam Chair.

Good afternoon and welcome. Health Canada's clients include, of course, the aboriginal and Inuit population. The Auditor General's report was rather critical of the rather low number of indicators for studying or describing the state of health of aboriginal and Inuit communities, and it stated that more specific indicators have to be used for that population.

Given that Health Canada has acknowledged that its indicators are rather limited and are not able to follow changes in the state of health of aboriginal and Inuit populations, will the 2008 report indicate any improvements?

[Dr. Karen Dodds]

Thank you for the question.

Health Canada, as you've noted, does provide a range of health care programs and services to first nations and Inuit. We don't provide all health care services, and much of the difficulty in collecting data is the fact that we don't provide all services.

We do continue to support the collection of data. We have supported the First Nations Regional Longitudinal Health Survey, which is administered by the Assembly of First Nations. Results from the first cycle of that survey were released in November 2005, and we've committed $12.5 million to support infrastructure, data collection, and dissemination for the next survey, with results expected in 2010. So the frequency with which we get data on the first nations and Inuit people doesn't match our two-year cycle for Healthy Canadians.

We've also contributed $5 million, in collaboration with other departments for a total of $40 million, to fund Statistics Canada's 2006 on- and off-reserve Aboriginal Peoples Survey. That's an omnibus survey that collects information from first nations, Inuit, and Métis on health and social determinants of health indicators. That information was released in December 2008, and we look forward to further studies on that information.

We're an active participant on the federal-provincial-territorial task force on aboriginal health data and indicators, which is overseeing provincial- and territorial-led pilot projects aimed at improving existing aboriginal health data sources.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

From what I understand the next report will not include any clear improvements with respect to the Auditor General's assessments or observations.

[Dr. Karen Dodds]

We have added 19 comparable indicators for the Canadian population but not for first nations and Inuit populations. At this point in time we do not have the data to allow us to do that.