EVIDENCE

[Recorded by Electronic Apparatus]

Thursday, May 18, 1995

.0933

[English]

The Chairman: Order, please.

Good morning, everyone. We welcome the minister. Bienvenue au ministre. We're delighted to have my good friend and colleague, the Minister of Health, with us this morning. We invite the minister to make a brief statement.

We have many questions for you.

Hon. Diane Marleau (Minister of Health): Thank you, Mr. Chairman. I'm always pleased to appear before you. I do have a considerable number of things to say to you before I let you ask me questions.

.0935

[Translation]

I am pleased to appear before your committee once again to discuss my department's main estimates.

As a former associate Finance Critic and Chair of the Finance Committee of the Regional Municipality of Sudbury, I have always supported careful scrutiny of public spending. Canadian taxpayers demand that we spend their tax dollars wisely.

This morning I will review what I have concentrated on since my appointment and outline my priorities for the coming years. I will then be glad to answer all your questions.

The more I consider my responsibilities as health minister, the more I realize they are about providing a sense of security to Canadians. At a time when so much is changing in Canada and in the world, people need security to cope with change. They expect their governments to play an important role in that regard. I do not mean this in a paternalistic sense. I strongly believe on the contrary in individual responsibility. But only government can provide the benefits of universal health insurance, ensure the safety of drugs, and invest the hundreds of millions of dollars required for health research.

Other members of Cabinet play a key role in providing Canadians with a sense of security. As members of the Standing Committee on Health, you understand the special role of Health Canada. When we think of security, safe streets are a vital part of personal security; but, day to day, safe food, safe water, safe drugs and knowing that you will looked after if you fall ill, regardless of your income, or perhaps even more important.

[English]

Ladies and gentlemen, let me now turn to what we've accomplished. I will not review the red book's health commitments in detail this morning, but I want to tell you that I'm proud of these programs. I'm particularly proud of the two devoted to the health of children: the aboriginal head start program and pre-natal nutrition.

Having heard from Fraser Mustard, you no doubt have a full appreciation of current scientific thinking on the importance of a healthy childhood, particularly from birth through the pre-school years. I understand that the members of the National Forum on Health have also appeared before this committee.

The outstanding Canadians we have appointed to the forum have taken their work very seriously and are now in a position to offer advice. They're concentrating on four main themes: determinants of health, evidence-based decision-making, values, and striking a balance. The latter's theme is concerned with the need to use our limited resources in a balanced way to achieve the best outcomes.

At their meeting on March 15 and March 16, forum members confirmed their support for the principles of the Canada Health Act and for public funding of the health system. The forum now has approximately 50 projects under way, and it will begin a process of public dialogue in the fall of this year.

The fourth red book commitment I've met is the launching of the centres of excellence for women's health. After seeking the views of hundreds of women across the country, we're preparing to invite interested groups to submit their intent to bid by the end of May.

As well, I'm pleased to say that I'm exploring the possibility of a joint conference on women's health with U.S. Secretary of Health and Human Services, Donna Shalala.

In addition to these specific initiatives, I've been fully engaged in the defence of medicare. I invite you to think about what we have accomplished - forget the rhetoric, look at the facts.

Last September at a meeting in Halifax, all health ministers agreed to work cooperatively to uphold the principles of the Canada Health Act. This kind of federal-provincial entente should be underlined.

Also in Halifax, all ministers present, except the Alberta minister, agreed on the need to regulate private clinics. As a result, on January 6 I sent the provinces an interpretation letter on the Canada Health Act. I asked them to eliminate situations in which private clinics offer medically necessary services and charge patients a facility fee, and I'll return to this in a minute.

.0940

During this period I've also shown that I will use the powers of the law when appropriate. In May 1994, almost a year ago today, we began deducting $1.7 million from transfer payments to British Columbia in order to discourage extra billing. The Canada Health Act provides for dollar-for-dollar deductions for these provinces that allow physicians to charge extra for medically necessary services.

We have grappled with many other tough issues. The committee is familiar with the Tobacco Demand Reduction Strategy, developed as part of the government's anti-smuggling action plan. I'll have more on this later, but I want to tell you how much I appreciate your support on what continues to be a very difficult file. You will be pleased to hear that last week the annual meeting of the World Health Organization adopted a resolution we had co-sponsored that calls for the development of an international convention on tobacco control.

It is hard to find a role more central to the security of Canadians than the safety of our blood supply. Of course, we are awaiting Justice Krever's final report on this matter. In the meantime, I have taken action to reinforce ongoing regulatory procedures and practices within Health Canada related to blood and blood safety.

[Translation]

One of the most sensitive issues we face concerns new reproductive technologies. Having discussed this with the ministers of health of several countries, particularly Mme Simone Veil, I know that this is one of the toughest issues with which we must deal. I have consulted with my provincial colleagues as well, and I expect to announce interim measures in the near future.

I have said, since taking office, that breast cancer would become one of my Department's priorities. Following the extremely successful National Breast Cancer Forum, in partnership with the Medical Research Council and the National Cancer Institute of Canada, we have funded over 24 projects for $6.8 million study issues like prevention, treatment and supportive care for breast cancer.

It is often forgotten that two-thirds of the budget of my department, excluding transfers to provinces, is devoted to native health. At a time when most government programs are being cut back, I have been able to secure continued growth in funding for this sector, as announced in the last budget. I have invited the leaders of the First Nations to work with my department in identifying ways of achieving the lower targets it provided. And I announced just last week the establishment of six permanent treatment centres to combat solvent abuse in aboriginal communities.

However, our major focus is, and will continue to be, the transfer of control of programs to First Nations themselves. Along with many other initiatives, I think these illustrate our government's commitment to redressing what are really inexcusable health inequalities.

I will not enumerate the many important health promotion activities of my Department, but I do want to highlight our work on AIDS, family violence, and our assistance to vulnerable seniors.

[English]

Defining, assessing, and managing current and emerging health risks are among the responsibilities of the Health Protection Branch of Health Canada. This branch plays a unique role in ensuring the safety of the country's food, drugs, cosmetics, medical devices, and consumer products and in sustaining the country's health protection infrastructure.

Canadians look to Health Canada for reassurance whenever there are natural or civilian disasters or threats to national health from chronic diseases, such as cancer and tuberculosis, or communicable diseases such as AIDS/HIV or the Ebola virus. To track and understand threats to the health of Canadians, we are strengthening our health intelligence network to share data and research with our provincial and territorial colleagues and to enable us to make cost-effective choices regarding risk management and the use of new technology.

Here I want to say a few words about management, a topic we ignore too often. When I assumed this portfolio, I advised my officials that value for money was one of my main objectives. I deeply believe in the mission of Health Canada, but I want it carried out without frills. I'm prepared to spend more money when I think it's called for, as I believe it is in the fight against breast cancer. But I have no time for waste.

I asked the department to review its spending in a number of areas, such as common services and laboratory operations.

By streamlining the management of common services such as financial management, assets, and informatics, we expect to save up to $6 million. Consolidating our laboratory operations is expected to generate $8 million in savings by 1997-98. This is what I mean about spending smarter.

.0945

With a personal priority of that nature, you'll understand why I welcomed program review. In recognition of the importance of health, our cuts were not as deep as in many other departments. But we took advantage of program review to carry out significant internal reallocations in order to fund new priorities, such as the improvement of our health surveillance capacity.

We also decided to focus the work of the department on four main business lines: health system support and renewal; population health strategies for groups at risk; delivery of services to first nations, Inuit, and Yukon; management of risks to the health of Canadians - products and disease control.

I want to take this occasion to underline the dedication of my officials. I believe I forgot to introduce them. I have my deputy minister here, Michèle Jean; Kent Foster, whom you know; and Orvel Marquardt, DG Finance. I want to thank them for what they do, because they work very hard to serve Canadians.

I'll turn now to my priorities for the next year.

The Chairman: Excuse me. Before you go further, we're getting into a logistics problem. We were told we had you for only an hour. We told your people we would like a very brief statement, and we would like some opportunity to ask you questions. So we can do it one of two ways: either you can cut short what you're saying or you can agree to stay longer. We do have some questions we want to put to you.

Ms Marleau: I'm here to serve you, Mr. Chairman.

The Chairman: All right, so you'll stay longer.

Ms Marleau: I wouldn't mind going through some of my priorities. My problem is that I'm on House duty, and you know what that's like. That's my reason for the time constraints. But if you want to let me go with a few of my priorities, I'll try to cut it down.

First, I want to continue to defend the principles of medicare, because Canadians have a strong attachment to their health system and the federal role in it. In fact, according to Angus Reid in March 1995, almost all Canadians want national standards in health care, with 94% saying such standards are somewhat or very essential.

In view of the need for fiscal restraint, this will continue to be a challenge. I remain convinced of two things: first, the principles of medicare are as valid now as ever; and second, it is the alternative being proposed to medicare - two-tier medicine - that we cannot afford as a country.

With respect to medicare, I'll give you the next steps. I have invited my provincial and territorial counterparts to meet with me in Ottawa in late June, after their recent Vancouver meeting. We will continue our discussions on the Canada Health Act and on health system renewal. In parallel, there are discussions among officials to review progress on the follow-up of my January letter to provinces on private clinics and facility fees. On October 15, in the case of those provinces that continue to allow facility fees for medically necessary services, I will start the enforcement process provided for in the Canada Health Act.

Throughout this period I will continue to work with my provincial counterparts on initiatives designed to bring health costs down. I'm particularly interested in bringing down the cost of drugs, which is the fastest growing component of health spending in this country.

[Translation]

Regulating products is essential of course, but health protection also requires that we have in place surveillance systems that allow us and the provinces to anticipate problems and find timely solutions.

.0950

The February budget announced that Health Canada would be reinvesting any savings from planned expenditures in areas where we can exercise federal leadership, such as public health intelligence networks. This will include better international networks, through the World Health Organization and the Centers for Disease Control and Prevention in Atlanta for example. Thanks to our current efforts in this area, we are able to be up to date on events in Zaire concerning the Ebola virus.

Let me say this morning that the risk to the health of Canadians is extremely low, but we have in place the measures that will allow us to react really quickly should any threat emerge.

I would just like to say a few words on generic packaging, one of the measures outlined in the Tobacco Demand Reduction Strategy. You are all familiar with this issue, as a result of your in-depth study and I want to thank you for your excellent work. You are aware, I am sure, that I will make the final research report public tomorrow.

[English]

Building on what we've already put in place, I've asked my department to place a high priority on women's health, and we have already a significant number of activities and initiatives that bear directly or indirectly on the health of women. I'm going to continue working in that area, especially with the arrival of the centres of excellence, which I hope will be starting work in early 1996.

I can go into what we're going to do with research, but you can get that in questions and answers.

In conclusion, Mr. Chairman, let me return to my main theme: providing Canadians with a sense of security - providing them with a sense of security when they know they will be taken care of if they're sick, when they know the products and drugs they use are safe, and when they see the measures we take to prevent disease. This is what we must do to earn the trust and confidence of Canadians. We will strive to do our work with excellence and integrity.

If you're ready, ask me any questions you wish.

[Translation]

Mrs. Picard (Drummond): Good morning, Minister. Welcome to the Committee. I have a few questions on the Canadian Bureau of Biologics.

I would like to know if you have increased the operating budget of the Canadian Bureau of Biologics, if the Bureau has developped suitable training programs for those responsible for the inspection of blood supplies centres, and, finally, if any more people have been hired for the inspection of blood supply centres and the laboratory analysis of blood products?

Ms Marleau: If you do not mind, I will ask Mr. Foster to answer since these are very specific questions.

Mr. Kent Foster (Assistant Deputy Minister, Health Protection Branch, Health Canada): We can generally answer yes to most of your questions. To give you more details, we have a new team in charge of blood pathogens. As well, we have doubled the number of employees dealing with pathogens within the Canadian Bureau of Biologics.

[English]

We have also produced good manufacturing guidelines for manufacturing, controlling, and processing biological drugs, including blood, blood components, and blood products. We have developed proposals for international chains of inspectors. We have an inspector training program in place.

.0955

We are making all the results of our inspections public by way of exit notices, and we are always reviewing our regulatory policies related to inspection of hospital-based blood and blood component manufacturing processes. We are of course waiting for Krever's final report and his recommendations, but we are doing those things we feel need to be done to ensure Canadians have safe blood and a safe blood supply program.

I apologize if I've missed one or two of your specific questions. Perhaps you'd like to redirect them for me.

[Translation]

Mrs. Picard: I would like to know whether or not the Bureau's operating budget has been increased.

[English]

Mr. Foster: Yes, it has been increased by reallocating funds within the Health Protection Branch and by reallocating funds within the department.

[Translation]

Mrs. Picard: Thank you, Mr. Foster.

[English]

Mr. Hill (Macleod): I'd like to start by going to an overview of what this process is, and I'd like to read to you a politician's statement about review of the estimates.

In Canada, ministers can be called to committees, but because of a host of practices, including the tradition of short meetings and windy replies by ministers and officials on the government estimates, the oversight role on public spending is effectively non-existent.

He went on to say that only one item in history has been reduced in the estimates by a committee, that being a $20,000 item, back in 1969. It turned out that the item at issue had already been spent when the committee voted to block it.

Since we're here to review the estimates, do you feel this process is useful to the Department of Health - to review, look at, turn over, and be really vigorous with these estimates?

Ms Marleau: I think it's very important that you review them with a lot of vigour, but you can also give us the areas on which you think we could concentrate more in the future, so we can also gauge the questions your constituents are asking. You can also ask the officials and me the tough questions that need to be asked.

There is no doubt in my mind that the more we work at this, the better we'll become at it. But you also have to remember that we have just gone through a very rigorous program review exercise within the department, that there have been considerable cutbacks in certain areas, especially in light of the fact that over the last 10 years there have been cuts with the previous government, I believe.

We're taking this work very seriously, and I think it's very important that everyone know just how seriously we take this work and our responsibilities to spend more wisely, while guaranteeing that the work we have under our responsibility gets done. It's important that we can assure Canadians that we are here, that we are doing excellent work in terms of protecting both the Canada Health Act and the safety and security of the products people must consume, and on down the list.

Mr. Hill: Really, what I'm after is a commitment from you, as the minister. I'm not so naïve now, as I may have been a year ago, to think an opposition member of this committee is going to have a profound impact. But if this committee, and particularly the Liberal members of this committee, came up with a significant item in the estimates that they felt needed to be reduced and if, in fact, it were the will of this committee, what would the chances be of that coming to fruition? What would the chances be of a historic event in Canadian history whereby a committee actually, physically did something useful in the estimates?

Ms Marleau: I would certainly be very willing, on a very open basis, to consider the recommendations of the committee.

.1000

If, for instance, you wanted to recommend that we stop spending in certain areas where legitimately we may be spending too much money, I'd certainly want to sit down and discuss that. Mind you, you're not giving me any examples of the kinds of things you might suggest.

Let me tell you, I personally know of the difficulties I've had with program review, knowing that I had to spend less money on things that are very important. But there is no doubt in my mind that if the committee has useful suggestions to help me in my work, I will certainly take them very seriously.

Mr. Hill: So that is a commitment then, if this committee made a recommendation, we could see an estimate reduction in -

Ms Marleau: I said I would take it very seriously, and I would analyze it and respond to it.

Mr. Hill: In light of my feelings that it's not likely the suggestions will be well listened to coming from me, I turn the time over to my colleagues, who I think might have a better chance of having this out.

The Chairman: That's a marvellous precedent, Grant. Thanks very much.

I was remiss in not recognizing earlier two of our colleagues who, although not members of this committee, are here filling in and, more to the point, have a great interest in the subjects at hand: from Guelph-Wellington, Brenda Chamberlain; and from Beaches-Woodbine, Maria Minna.

Our next intervener is Paul. That will end the first round, and then we'll go to the second round.

Mr. Szabo (Mississauga South): Good morning, Madame Minister.

Following Grant's line of questioning, I want to recommend to you an increase in the estimates -

Ms Marleau: I'd like that, but I think no matter what I do, you'll have to get the okay from -

Mr. Szabo: - in the context of need. You did say in your presentation that you would be prepared to reprofile or refocus if the need was demonstrated.

Dr. Elgie appeared before the committee...and you mentioned that drugs is one of the fastest growing expense areas of the Department of Health. Their budget is somewhere in the neighbourhood of - I don't have the numbers - $3 million, yet they've never conducted a full hearing, and we are getting into a new round of the whole question of generic drugs, and so on.

I've raised that, but it's certainly not the area I want you to comment on. I'm most interested - and I'm sure everybody else is - in the vision, the strategic direction in which we are going.

Through all the work this committee has done, we have found a great deal of support and evidence that early intervention has a significant impact on the long-term health care costs of Canadians. We also have been informed and educated about the impacts of an aging society and the fact that our health care costs are so significantly skewed to the twilight years of life.

Those changes are occurring, and I believe your comment about the importance of drugs is reflective of the movement of our society in terms of its age and our education in terms of the determinants of health. The health care budget now has a greater proportion of its focus centred on the remedial and the curative.

Is the department now prepared to come up with a strategy to shift more to the preventative side, particularly given that we do not in fact have any more money to spend, as it were, on health care? We are satisfied that there is enough money in the system, but it does need to move. As the minister, can you give us a little bit of your vision of health?

Ms Marleau: You've asked me two questions there, one of them about the Patented Medicine Prices Review Board and its budget. As you know, they have a new chairman, Dr. Elgie, whom you have met and who I know will do a tremendous amount of work. I too am very concerned about ensuring they have the means necessary to do their job, and I'm certainly willing to discuss with him any amounts that he feels he needs over and above what has been allocated, because I do think it's essential that they have adequate financing.

When it comes to population health, it is very much on our mind to ensure by every means possible that we invest in keeping people healthy, as well as treating them when they're ill.

.1005

A number of initiatives are happening, even within our department. The new business lines we're putting in place are very much targeting the population's health. That way we can make sure we integrate and spend our money in those areas that will be of the best value.

You talk about population health. The Tobacco Demand Reduction Strategy is a good example of the kinds of money we're placing in an area that can really help people remain healthy. If they stop smoking, they will stay a lot healthier. They will have a lot fewer health problems, and they will cost our system a lot less. That's just one example.

For instance, there is the pre-natal nutrition program. That's a program that shows you the real focus we have. We realize getting children started off well is important, so we'll invest in their mothers while their mothers are carrying them to ensure that they're born with the very best chance possible. Underweight babies have a lot of problems, not just health problems. They oftentimes have learning problems. We think it's absolutely essential, and we're going to do as much as we can.

The way the Canada Health and Social Transfer has been structured also allows us to look at the overall determinants of health, in one way. Not only should we be funding health care, but we should also be looking at the areas of jobs and adequate incomes. These are all determinants of health that show us we can do some things to improve the overall health status of people. We're very much into that.

Mr. Szabo: Thank you, Mr. Chairman.

The Chairman: In the second round, I remind members of the committee that both the questions and the responses ought to be briefer.

[Translation]

Mrs. Dalphond-Guiral (Laval Centre): Good morning to you, Minister and your officials. I have three questions to ask you. I will start with the one that concerns me the most.

In your presentation, you said that you would be announcing shortly interim measures concerning new reproductive technology. Everyone here knows about the anniversary coming up in November. Will you be waiting for that anniversary to take all those measures or do you intend to do it before the adjournment, before the 22nd or the 23rd of June? That' s my first question. Should I ask you the other ones now or should I wait? Perhaps you could give me an answer now, since this is such a short question.

Ms Marleau: We have done a lot of work in that area and we hope to have something to table before the end of this session.

Mrs. Dalphond-Guiral: You know that because the session has been adjourned doesn't mean that no work can be done.

Ms Marleau: Indeed, and we will have quite a lot of work to do. These are very difficult issues, as you know. We want to do whatever can be done right away and build on that later on.

Mrs. Dalphond-Guiral: Will these interim measures be costly?

Ms Marleau: I don't think so.

Mrs. Dalphond-Guiral: Very well. Since you didn't have much time, you skimmed over very quickly the part of your remarks on research. We talk about prevention, but in order to work at prevention, we have to know what to work on. It seems to me that research is one of those areas where budgets can definitely not be cut. In the reallocation of the department funds, was the research budget reduced, maintained or increased? I would like to know what percentage of your budget is spent on research. I would also like to know what percentage of federal funds coming from the Health Department is allocated to research in Quebec.

.1010

Ms Marleau: We'll have to get back to you because we don't have these precise numbers with us. However, I can tell you that when it comes to research, especially in terms of prevention I am working in close cooperation with the Medical Research Council in terms of prevention and system efficiency. We did have to cut their budget by 10%, but that is much less than what has happened in other departments. We recognize the importance of research in this field.

As I have often mentioned, the decision to cut a budget is always a difficult one, especially in the health field because we know that the decisions will have an impact on everybody, at all levels. So we had to make very difficult decisions. To answer your question, it is 10% over three years.

Within the department, funds to the Health Promotion Grants and Contributions Program were increased by approximately $3 million this year.

Mrs. Dalphond-Guiral: You talked about an agreement on the regulation of private clinics. That seems essential to me. If I understood correctly, you said that only one province, Alberta, has not yet signed the agreement. Has any action been taken against Alberta?

Ms Marleau: As I said, we sent a letter in January and we are awaiting their answer as to whether they will be signing the agreement or not. They haven't so far, I don't think.

Mrs. Daphond-Guiral: The department is very patient.

Ms Marleau: As I said in my remarks, we will take the necessary measures as of October 15. We have given them a deadline. That's the final date, and if we've had no answer on that date, we will take the necessary measures.

[English]

Ms Bridgman (Surrey North): Thank you very much for coming.

I have three questions. Two are related to money management, etc., and I'm taking a bit of liberty with the other one, because we have you at the table, to ask you to expand on something.

The first question is in relation to women's cancer in a general context. With budget cuts and that kind of thing, we are giving a lot of attention to the specifics of breast cancer. Are these budget cuts going to affect this program in any sort of major way? Could you reassure us that we're certainly looking at women's cancer, more so than just breast cancer?

Ms Marleau: It should not affect that at all. As a matter of fact, because we're bringing forward our proposal to create centres of excellence for women's health, we are very much hoping that these centres will help us in our work to concentrate more effort, not just by government because we don't have an infinite amount of money, but by other outside agencies as well, on setting the research agenda for all aspects of women's health and not only women's cancer.

Ms Bridgman: My second question relates to health services for aboriginal peoples. I'm not arguing there isn't a need there, especially in the north where there's limited access to the big centres. We spend a lot of money in this direction and I'm wondering, with the transfer of responsibilities for health services to the aboriginal communities, if there's a saving realized here. We've already done 27 or so health-care transfer agreements with - my notes say - 82 first nations and there are a number of others going on. Could you give us a little overview of how this process works, how much it is costing us, and whether the health department will realize a financial saving on this?

.1015

Ms Marleau: I think in the long run there will be financial savings, because the aboriginal communities themselves will stand better in the areas that are important to them. The whole idea is not so much to cut budgets while we're transferring authority, but for aboriginal communities to take control of their own health and their own distribution of funds to ensure the health of their communities. For too long either Ottawa or someone from outside has come in and told these people what is good for them, and it obviously hasn't worked. We certainly haven't saved any money.

Aboriginal communities are often not very healthy, so this has not been the way to solve some of the very serious problems faced by aboriginal communities. We're convinced that by allowing them to make decisions about their own health, within the budget structure, of course, they will spend and have the use of these dollars in a far more effective way in terms of their own health.

Ms Bridgman: So no specific programs will be cut out of this. It's just a matter of transferring them from a management and administrative point of view.

My third question relates to the Ebola virus, and we can use that as an example. My orientation into conditions of bacteria, viruses, or whatever that run the risk of becoming pandemic kinds of situations relates to the communicable disease kind of profile we had for smallpox and chickenpox 30 or 40 years ago, when they were some of our major concerns.

We now have a bunch of these little viruses running around our planet that are giving us great concern. I really don't see a Canadian profile or proactive plan like we had for communicable diseases. We quarantined, banged signs on doors, and that kind of thing. Could you tell us what is happening in this area? Do we have a plan?

Ms Marleau: We have a plan, and we're spending considerable dollars on health surveillance. To give you more details I'll turn it over to Dr. Foster. This is a very big concern of ours, and we have put considerable effort into this area.

Mr. Foster: We share those concerns. We have been finding gaps in our surveillance network and putting resources and funds into explore those gaps. To give you one or two examples, it's part of the health determinant approach the minister wants us to follow. We're trying to go from a ``diagnose and cure'' strategy to an ``anticipate and prevent'' strategy.

We are looking to fill these gaps in the following kinds of ways. In the Laboratory Centre for Disease Control, we've created a new section called the public health intelligence initiative to deal with blood-borne pathogens, for example. The research there will deal with such things as HIV/AIDS, Ebola, and other emerging and re-emerging pathogens such as drug-resistant tuberculosis. It will also deal with hospital-acquired infections and antibiotic resistances, cardiovascular and chronic respiratory diseases, risky sexual behaviour, infectious respiratory diseases, etc., in a program-strategic manner.

We are reallocating funds from within the department based on a risk management assessment of the risks as they appear and the risk benefit assessments. We're going to put our effort and resources into those areas from which the greatest benefit will come. We will obviously deal with the most risk.

I hope that's sufficient to give you a feel for what we're doing.

The Chairman: I want to put a quick question to the minister.

The chair was of the impression that the minister would have distributed the Outlook document this morning.

.1020

Ms Marleau: I thought we did have it.

The Chairman: The point is we don't have it.

Ms Marleau: I thought it was being distributed before the meeting.

The Chairman: We've had a few communication glitches with your department, Minister. We'll talk about that another time; that's not aimed particularly at you.

Ms Minna (Beaches - Woodbine): I have three questions, Madam Minister.

You mentioned, at the outset of your presentation this morning, the commitments with respect to the red book. I don't expect you to go through them, but would you say, at this stage of your mandate, that you have met most, some, or all of the commitments that were made in the red book?

Ms Marleau: I would say that I've met all of them. The one that is not completed is the centres of excellence for women, but we have done considerable work on it. As you know, we're putting out a call...and we hope to have them up and running by 1996.

Under our portion of the red book we had such things as the aboriginal head start program, pre-natal nutrition, centres of excellence for women's health, and the National Forum on Health, to name but some.

Ms Minna: My second question has to do with the concern of constituents in my riding with respect to two-tiered health care. To some degree, this has been whipped up because of elections.

The candidate in my riding is also a minister of the Crown in the province. The brochure and the letter that she has written to constituents says very clearly that the federal government is openly discussing the establishment of a two-tiered system of health care.

That's a very clear statement. Those who cannot afford...will get less. Those who can afford...will be able to get more.

Then there's the Alberta situation. I understand the government there so far has not agreed to abide by the principles of the Canada Health Care Act.

Could you tell me whether there is such discussion within the department with respect to looking at certain core services that we may change in a two-tiered system? Are we looking at breaking things up in some way? If not, at some point, are we looking to getting Alberta to respect the Canada Health Act?

Ms Marleau: We have had absolutely no discussion on allowing a two-tiered system; quite the contrary. We're very much concentrating our efforts on preventing a two-tiered system and on ensuring that the misinformation that is put out is countered.

The National Forum on Health is also involved in the discussion and has endorsed the publicly funded, publicly administered system we have and are continuing their work in that regard.

We are not, in any way, discussing a two-tiered system other than how to prevent it and to ensure the money that's there is used to the best advantage.

What we are doing, though, is working very closely with the provinces at helping them in a very difficult task, which is to change to meet the challenges that are with us.

The Medical Research Council of Canada, as well as our research branch, is looking at how we can invest in research on outcomes of many of the procedures in place now, so that Canadians can better be treated with procedures that are effective.

There's a lot of work going on in that area, but absolutely no work in terms of trying to destroy what we as Liberals have built and really believe in.

Ms Minna: I want to commend you for focusing on women and children, because to me preventative health is where the future savings are, not in treating just symptoms. This leads me to the next question.

.1025

Is the national health forum and the department looking, in some way, at expanding the research or the ways of dealing with medicine in a preventative way? We're looking at senior citizens, we're looking at community living; that's happening now in Ontario to some degree, but unfortunately the moneys aren't going with the community once the de-institutionalization or whatever one calls it takes place...the assistance. I believe this kind of preventative aspect of health care is probably the only way in the long term we are going to save moneys in the system, not so much by cutting back. If people are ill, they're ill. You're going to have to deal with it. Preventative health care seems to me to be the main way to deal with it.

The other issue is the money I see wasted in hospitals.

The Chairman: Bring it to a conclusion, please.

Ms Marleau: We're doing considerable work on promoting healthy lifestyles for Canadians. I could go through all the programs we have in place. We're very interested in having as much focus on these areas as possible, because we understand the long-term value of what we're doing. All of our programs have that component built in. We think it's essential. It isn't always easy, though, to be allowed the dollars in those areas. Even though we know that they save money in the long term, it's very difficult to account for in the short term.

In terms of pre-natal nutrition, we know what the costs of a baby born underweight are and the cost of keeping him in a hospital for 60 days or whatever. You really cannot measure the savings if it doesn't happen. You can guess at them, and they're tremendous.

Nevertheless, we're continuing our work and trying to convince all other departments of government also to look at their role and how what they do affects the health and well-being of Canadians.

We're very much aware that people who have good jobs tend to have a better health status; that's one key area. We also know the environment plays a huge role in the health of Canadians. Clean water, adequate food, and the proper kind of food play a major role in keeping people healthy and in saving us costs in the long term.

Mr. Patry (Pierrefonds - Dollard): I have two questions for you, Madam Minister, regarding the budget. First of all, in your budget plans of last February the federal government announced that, as a result of the program review, many programs would be reduced and some of the savings would be reinvested to address priorities such as enhancement of the public health information network, breast cancer research, pre-natal nutrition, and the aboriginal head start program.

The budget plan also mentioned that, excluding established program financing for health transfers, the Health Canada expenditure level would be reduced by $70 million over the next three years as a result of these decisions.

Can you tell us which programs will be reduced or even eliminated as a result of the last budget or which programs in particular will be targeted?

Ms Marleau: As you know, we have reduced...in a number of areas. We did reduce...in the tobacco demand reduction strategy. We've also slowed the increase in certain programs. For instance, on the community action program for children, we are not going to spend as much money as had been previously authorized. I can go down the list. These are some of the areas that we have considered cutting back on.

We have not cut back to date on AIDS funding. We have not cut back on breast cancer funding, although we don't have huge sums there. We're interested in increasing it, and we are finding ways to do it.

.1030

We have not cut back on funding for Indian and aboriginal health, other than cutting back on the projected increases that had been part of previous budgets. We're projecting a 6% increase this year, and 3% in each of the next two years.

We have cut back on the Medical Research Council by 10%. We have reduced many other programs so that we could meet these targets. I believe that as a department, we were spared in a lot of ways compared with what's happened in other areas.

[Translation]

Mr. Patry: Thank you. The estimates report that the staff of the Policy and Consultation Branch carried out an analytical investigation on health insurance and health care issues. Which issues were the focus of these analytical investigations? How many analytical investigations were conducted and what conclusions were drawn? If you cannot answer today, could you send your answer to the committee later on?

Ms Marleau: Let me ask Mr. Juneau who is in charge to answer.

Mr. André Juneau (Assistant Deputy Minister, Policy and Consultation Branch, Health Canada): The investigations aimed at supporting the efforts that the minister made in implementing the Canada Health Act. The investigations aimed for instance at defining the extent of the private clinics phenomenon and dealt more generally with the problems of health economy in order to demonstrate, with our colleagues from universities, that a publicly financed system is not only better for health but also more profitable from an economic point of view. Those were the types of investigations made.

I could not tell you this morning how many investigations were made, because we conducted some every day; but if you wish, we can send you a more detailed list of the investigations.

Mr. Patry: Yes, thank you.

[English]

The Chairman: We have two members who haven't intervened before. After they speak, I will entertain brief questions from people who have already asked questions.

Mrs. Chamberlain (Guelph - Wellington): Thank you.

Let me begin this morning, Madam Minister, by saying I thought you had an excellent presentation. I enjoyed hearing it. I am not a permanent member of this committee, and I found it extremely informative and valuable to be able to go out and talk to my constituents about what you're doing. Let me put this on the record. Thank you for that excellent presentation.

I also want to congratulate you on the good work you're doing, particularly in the breast cancer field. I think it is absolutely imperative, not only because I'm a woman but because I think it is a health issue for everyone. Please be aware that there are a lot of people who think you're doing a lot of good things.

There is an area I want to discuss today. I met recently with Dr. Kittle from my area who has a great deal of concern about our decrease in the prices of tobacco. We as a government have said we know there was smuggling, and we had to stop it, and we did stop it by decreasing prices, while also recognizing we had a lot of kids and people buying tobacco at a cheap price. We mustn't fool ourselves into thinking they weren't accessing this market. They were.

I feel strongly, as did Dr. Kittle, that the decrease in tobacco prices has increased smokers. I think the increase in prices was a deterrent. Recognizing that there are no silver bullets and no perfect solutions, and that we're trying our best with a very difficult solution, will the minister comment about things such as the fact that we are doing a great deal of education? I would say I think it's working and it is helping.

What can we do? Do you also agree that a reduced price in tobacco does encourage people to smoke more? What do we do about that? What are your future plans? How do we help that market?

Ms Marleau: First, I wish we hadn't been in the position we were in a year ago. It would have been far better if we hadn't had the contraband problem.

Let me also tell you that there's a lot of misinformation out there in terms of the actual increase in the use of cigarettes.

.1035

We have commissioned surveys. Much to our surprise, to date the surveys have not shown dramatic increases in smoking. I was very concerned with that. I believe the last survey, which, like the others, was very detailed and in depth, said that 150,000 fewer Canadians were smoking. That's a public survey. It's there.

Mrs. Chamberlain: Can you name that survey? Was it Statistics Canada's?

Ms Marleau: Yes. As a matter of fact, there's a cycle four about to come out. This was a cycle three, and it's public.

That does not take away the very real concern I have, especially in terms of young people and their access to tobacco products. Of course, the price plays a part in that area. I'm very concerned about the numbers of younger people taking up smoking and about the easy access they have to tobacco products.

We're aware that if people don't start smoking before the age of 18 or 19, they don't, by and large, take up smoking after that. It's very important for us to get to those young people. If we can prevent them from taking up smoking, within a generation we'll have cleared up that problem. Otherwise, we're looking at major health costs and problems for many years to come. It's especially a concern of mine that very large numbers of young women are taking up smoking. As a result of the tobacco demand reduction strategy, we have a number of programs addressed specifically to young women to try to prevent them from taking up smoking and to encourage them to stop if they have taken it up.

One of the things that happened a little more than a year ago was that the whole tobacco and smoking issue was brought to the forefront. That's very good.

The other thing we were able to do is institute a surtax on the tobacco companies' profits. We're using their money to fight smoking. We've done a considerable amount of work within the country, and some internationally. We've had the World Health Organization adopt a resolution we co-sponsored to look at an international protocol having to do with tobacco reduction. I think that's a major step. We still have a lot of work to do.

Tomorrow I'm going to be releasing the plain packaging study we commissioned.

We're going to keep working at it one step at a time. But the more public information there is, and the more we encourage people not to smoke, the more difficult it is for young people to access tobacco products. We have done considerable work in that area with the provinces in terms of hiring enforcement officers. We really mean business here. We want to make sure every store that sells cigarettes stops selling them to people under the age of 18 or 19.

Mr. Jackson (Bruce - Grey): Good morning, Madam Minister.

One of the frustrations I hear from women's groups from time to time is that they really haven't found a cure for breast cancer. When the research branch was here they said it was hard slogging, and in fact they had just found that the density and some genetic links could perhaps tell them who is at high risk. It seems there is not a lot of movement in that direction, except for the fact that they can tell who would be at risk.

Has any work at all been done that has really improved the health of women and stopped some of the major surgeries being used that may be disfiguring them?

I have a second question. When we talk about health care, we're always saying that Canada has one of the best systems in the world. There's always this temptation to experiment with a business approach like they use in the United States. We know our system works well, and we know 10% of GDP is probably adequate and perhaps high. You're talking about outcomes as well, and the outcomes would be the template for any particular illness, as to how it would pan out in terms of the resources put into it.

.1040

I would like to know how the departments are making out with these outcomes. I know since we've had the Hall report, for instance, we've learned that we can't warehouse people. Hospitals are very expensive.

Some of the techniques of surgeries are such that people don't stay in hospitals very long. Over the years, we've got these things like imaging equipment that have ``sex appeal''.

If people were ill in the good old days they got to go into a doctor's, and the doctor just looked at them, and said, well you've got cancer, you've got six months, go home and prepare to die. Now you say, well, I want a second opinion and a third opinion, and I want a CAT scan and I want some other scan and what have you.... In our society, you don't want to turn people off and you don't want to make non-citizens of persons, so we allow them to go through all these processes, although the prognosis is dire.

How are we making out with these? I suspect that's one of the problems we have with the way health care has been going. There are layers of professionals. As I've said, in the old days, you might have had only one doctor. Now you have a battery of them for any particular illness. How are we doing with that in terms of cost-effectiveness?

Ms Marleau: A lot of work is going on in terms of outcomes. A lot of work is being done at the provincial and federal levels, both by the Medical Research Council and by us. A lot of joint work is going on with the provinces. My provincial colleagues and I recognize this is very important work that has to be done.

You're right. It's evaluating the effectiveness of a lot of procedures. More has to be done, but a lot has been done, and will continue to be done. Also, we work with the Canadian Medical Association at disseminating information, because there are practice guidelines for physicians as well. Getting the information after you've done the actual work is also very important.

There's a lot of effort we have put in and will continue to put in to ensure that we use all of these new technologies to best advantage in a very cost-effective way and that we don't over-use them if it's not necessary.

You've also asked about breast cancer. I think the tragedy of breast cancer is that it's taken so long for the focus to be put on breast cancer. Women have been dying of breast cancer for years. By and large, the focus was not on looking at cures for breast cancer. I'm pleased to say that has shifted dramatically in the last few years. A lot of work is now being carried on.

We're also involving the women who have suffered from breast cancer in a lot of the decisions and a lot of the protocols that are being examined. I think that's a new, innovative way of dealing with it. We still have a lot of work to do.

The Chairman: We're getting very near the end of this session. The minister indicated she wanted to leave by 10:30 a.m., but she's kindly agreed to stay a little longer. There are three members who have already spoken and who would like to make other interventions.

[Translation]

Mrs. Picard: Madam Minister, my question deals with the non-insured health benefit program for the status Indian and Inuit population. In 1993, the Auditor General noted that Health Canada had not met its commitment in terms of accountability for program results and that the program information contained in the estimates was inadequate. Furthermore, the lack of information made it very difficult to evaluate program effectiveness.

What efforts has the Department made in 1994-1995 to improve the situation? How is Health Canada planning to evaluate this program? What criteria will it use? Finally, in your opinion, is this program effective?

Ms Marleau: We have done a lot of work in that area. As you know, we face very special problems.

If you wish, I could ask Mr. Cochrane to give you more details on the activities he has undertaken in his sector.

.1045

[English]

Mr. Paul Cochrane (Acting Assistant Deputy Minister, Medical Services Branch, Health Canada): We have made many different interventions since the Auditor General's report was tabled. Maybe one could best look at the outcomes here. In the three years prior to and including the year the report was tabled - in 1993 - the overall costs of the program had grown approximately 14% to 15%.

One also has to look at what contributes to those costs. The population receiving the benefit has grown approximately 54% over the past 10 years. At the same time, the overall Canadian population has grown about 11%. So you have a population that is growing much faster than the average population, and you have a population whose health is significantly more at risk. Those two factors also contribute to any growth in this program.

Since the Auditor General's report and last fiscal year, the growth of this program had been reduced approximately 6%. That was done through administrative and management practices and through greater clarification of what benefits are available and who the beneficiaries are.

I think the key piece of the resolution is that first nations have not had the benefit levels or the benefits reduced during that time. Following up on the recommendations of the Auditor General, we've been able to bring greater clarity and greater efficiency to the program, while not diminishing the benefits to first nations.

Mr. Hill: The federal government is spending $1,522 per person on debt servicing now, and $268 per person on health care. That's not likely to improve in the near term. Is the minister concerned about the declining cash transfers to the provinces?

Ms Marleau: I'm always concerned about our debt and deficit, with the dollars we have at our disposal, and with utilizing them well. I think having the block transfer will give the provinces an overall choice as to where they wish to spend the dollars transferred to them. I think that's very important.

There's also one very important point to make here. There isn't one economist in the country who says it's more money that's needed in the system. It is better use of what we have within the system. I think it's very important to say that.

Mr. Hill: Would you agree the money is going down?

Ms Marleau: The overall money to health can remain the same if the provinces wish to concentrate the dollars in those areas.

Mr. Hill: That's if the population growth....

Ms Marleau: It has not gone down to date. It is not projected to go down in terms of the overall transfer until next year.

Mr. Hill: Proportionately per person, the money is going down, is it not?

Ms Marleau: It has not gone down since we've been in office. It's growing at this time.

Mr. Hill: We strongly disagree.

Ms Marleau: The per capita is growing this year. Next year it will reduce.

Mr. Hill: The money for health care will reduce proportionately over time, will it not?

Ms Marleau: The overall transfer will reduce over time. Basically, it's also a function of tax points. Tax points are worth more than dollars. We are working at getting our debt and deficit in order and facing that problem, as the Reform Party goes on and on about our doing.

I think it is only the responsible thing to do, and we have taken far more cuts within our departments than we're asking the provinces to share. The provinces then have to make decisions based on their priorities.

.1050

Believe me, Mr. Chairman, health is a priority for all Canadians.

Mr. Hill: The minister said that it made sense to move the native health programs as close as possible to the natives, that they would be more responsible for it. Would she agree that, philosophically, the same would apply to the provinces?

Ms Marleau: Let me tell you it is that way now with the provinces. The provinces manage their own health care systems. The federal government sets principles or parameters that protect all Canadians, not just poor Canadians. What the Reform Party proposes would leave most Canadians very vulnerable.

Ms Bridgman: I'm thinking of the Hazardous Information Review Commission. I think it was created 10 to 15 years ago through legislation. It's my understanding that at that time cabinet mandated that it was to pay for itself through a cost-recovery kind of program.

The last estimates showed a cost recovery for 1984-85 of 28%. If it has been in existence for 10 to 15 years, allowing for a time to get started and that sort of thing, how long are we going to persist with this program when it's not achieving that mandate of cost recovery?

Ms Marleau: That's a very specific question. Is there anyone here who can answer that?

Mr. Orvel Marquardt (Acting Assistant Deputy Minister, Health Canada): No, I'm sorry. We would have to talk to that commission and get an answer back to you.

Ms Michèle S. Jean (Deputy Minister, Health Canada): It has its own estimates.

Ms Bridgman: My point is that there doesn't seem to be a parameter of when to achieve that objective. I'd like to know that.

The Chairman: I would like to thank the minister on behalf of the committee. I thank her also for the Outlook document. It allows me the opportunity to say I wish the devil we had had them before. They would have been much more useful if we could have looked at them in tandem.

Ms Marleau: That's true and it was my understanding you would -

The Chairman: That brings me to the real issue we want to bring to you and your officials while you're here. This committee doesn't exist in competition with the department. It's here to work and we have the same objectives. But you heard me mutter about communication glitches. I won't take you through them all this morning, but the bottom line is that there's an almost adversarial relationship that shouldn't exist between us and the department. It's like pulling teeth all the time to get information.

This is a beautiful example this morning. I looked in the document and couldn't see any state secrets or plans to drop the atomic bomb or anything, yet it was sat on for weeks. We've been praying and begging for this and got some of the most convoluted answers from some of your people over there. It breaks my heart.

I say that constructively and not to put you on the spot, Minister. As you know, I have great personal affection for you and you have the support, I believe, of most parliamentarians in this room. That's not the issue. The issue is that we can all achieve our common objective a lot better if we adopt Mr. Chrétien's undertaking of a little more open government. Our experience with the Outlook document was not a good example of that, to put it bluntly.

We thank you, Diane, and all your officials. We've had a good series of sessions with all of them, and it has given us a good opportunity to begin to get to know some of the people who we believe share the same objectives we do.

.1055

The regular committee members should stay for two minutes.

I want to tell the regular members that tomorrow at 8:30 a.m. there will be briefing on the tobacco strategy chaired by Ovid in room 237 Centre Block. We will reconvene May 30 at 9 a.m.

The meeting is adjourned.