In health policy, Stephen Harper's administration will be known preeminently for the fragmentation of the Canadian health care system.
During the 2015 election campaign the Conservative party offered no substantive health policy platform, maintaining that health policy was a matter solely for the provinces. The CPC noted, correctly, that under the Harper administration funding continued to increase. But it disingenuously refused to acknowledge that its revision of the funding formula increased the gap between the health care dollars that provinces received and the health expenditures they needed to make. The new formula penalized those provinces with the oldest and sickest populations and rewarded only the wealthiest province with the youngest population. That the original transfer formula negotiated in 1977 took these regional disparities into account was conveniently forgotten. While the previous Liberal administration only weakly upheld the requirements of the Canada Health Act, the Harper administration did not even pretend to monitor whether provinces respected the Act. The increasing health disparities between the provinces, and the incapacity of many if not all provinces to redesign effective and sustainable health care systems, means that, at the end of the Harper era, it is difficult to discuss Canadian health care as a coherent “system”.
Yet decay can also drive change. Under the Harper administration, the provinces were obliged to focus more upon repairing their own houses than on strategizing how to squeeze more cash out of Ottawa, as they had done in the 1980s and 1990s. It made the provinces think more about collaboration in the absence of any “first among equals” federal presence. But the devolution of national health policy to the provinces under Harper was limited in what it could achieve. Bending the cost curve in many provinces was achieved at the expense of sustainability,because provinces tended to contain costs by cannibalizing infrastructure, cutting maintenance budgets, and eliminating community-based programs.
So how do we move beyond Harper’slegacy?
The first step is conceptual. We have to understand that the health care system is no longer just a collection of doctors and nurses practicing more or less independently in their local communities, and responding only to local data. The emerging 21st century health care system will increasingly bedriven by our capacity to collect, interpret, and apply huge amounts of data effectively and precisely. To build these data sets, we’ll need to be able to share data across regions, across provinces, with the private sector (eg, pharmacies and home care agencies), and with Canadians’ own personal technology platforms. This isn’t a task that provinces can tackle on their own. Few – if any — have the financial resources or technical expertise. More importantly, if the goal is to share data, then success means common technical standards and principles for the protection of patient information.
So the second step is find a new institutional model whereby the provinces can work together. Because data sharing is built on standards and because standards constantly evolve, we need a dedicated and permanent secretariat to provide consistency and continuity in operations. This secretariat must be owned by the provinces and territories.The history of the internet shows time and again that the technologies that successfully unite communities are those built from the bottom-up by innovative users.In this case, it is the provinces and territories who will implement the standards and will learn, by experience, what works.
What would these new institutions look like? One possible route forward has been suggested by the Advisory Panel on Healthcare Innovation (the ‘Naylor Report’), which the Harper government commissioned, but then failed to support. The report called for the creation of a federal “Healthcare Innovation Agency of Canada” with a budget of no less than $1 billion annually. This is a good idea. But this agency can’t be a federally-controlled, top-down agency. Provinces remain cynical of federal involvement in provincial policy areas. What is needed is not an agency in charge of innovation, but rather an administrative support unit funded by Ottawa that can facilitate policy development initiated by and driven by the provinces.
The dilemma for the provinces is that, on the one hand, they will no longer accept any health policy driven by Ottawa; but, on the other hand, they do not individually have the capacity to build a 21st century health system. They need to find a path work together, facilitated but not directed by the federal government. Hegel feared that humanity can only grasp what it needs to do after theopportunity to accomplishit has passed. Yet, if Canada can meet this challenge, it can once again become known for its innovative, sustainable, and humane approach to health system design.
Photo: Stephen Harper – Facebook / Fair Use