[Recorded by Electronic Apparatus]
Tuesday, November 28, 1995
.1535 
[English]
The Chairman: Order.
Our order of reference is Bill C-95, An Act to establish the Department of Health and to amend and repeal certain Acts.
Our agenda for today includes the hearing of witnesses. We have, from the Canadian Pharmaceutical Association, Noelle-Dominique Willems. With that, I would like to resume consideration of clause 2. I ask our witness to introduce herself and her organization. I understand there's a brief.
Is it available to everyone?
Noëlle-Dominique Willems (Director, Government and Public Affairs, Canadian Pharmaceutical Association): Thank you, Mr. Chair.
[Translation]
My presentation will be made in English, but I will answer questions in French if you so wish.
[English]
The Canadian Pharmaceutical Association appreciates the opportunity to appear today before this committee studying Bill C-95, an Act to establish the Department of Health and to amend and repeal certain Acts.
CPhA has over 10,000 members, representing all fields of pharmacy in all provinces and territories. Our members include community pharmacists, hospital pharmacists, academic and research pharmacists, students, interns, and administrators.
Our code of ethics states that a pharmacist shall hold the health and safety of the public to be of first consideration in the practice of the profession, rendering to each patient the full measure of his or her ability as an essential health care practitioner.
In the case of the bill currently in front of us, CPhA feels it is its duty as a health care organization to raise some concerns about the separation of social programs that impact directly or indirectly on health from the purview of the Minister of Health. We feel that the minister's responsibilities of safety and health promotion would be easier to fulfil with appropriate programs and adequate funding.
It's because I'm an old political hack that I know all this, but I'll do a little review of the historical background of how this split happened.
In 1993, then Prime Minister Kim Campbell embarked on a process to try to rationalize the numbers of federal departments, based on an analysis that had been circulated by Mr. de Cotret and Mr. Osbaldeston on restructuring and rationalizing government.
The process led to a redistribution of the various functions within government, and mostly aimed to reduce the federal operating costs. Though the rationalization took place and some economies were realized, one cannot help but question the basis for some of the decisions that were made at that time.
The shifting of programs resulted in a transfer of the welfare component of Health and Welfare Canada, which Bill C-95 intends to make official, to a refocused department called Human Resources Development, HRD, formerly known as Employment and Immigration.
The intent was to group all the income replacement measures, pensions, social assistance, and unemployment insurance under the umbrella of the new department. In doing so, the programs were considered to be economic programs exclusively and the social reason for their existence does not appear to have weighed much in the decision.
However, in 1995 we're faced with a changing environment and a few new factors need to be taken into consideration in order to get a fuller view of where we're headed.
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In October 1994 the Prime Minister established the National Forum on Health in order to review the Canada health care system and to propose recommendations to render it as efficient as possible. As they embarked upon this major endeavour, the members of the forum selected by the Prime Minister felt that the determinants of health were such an important factor that one of the four working groups should be dedicated to studying them.
In doing so, they are looking again at the economic and social factors that directly impact on health. They will undoubtedly use the data provided by the National Institute on Child Health in its 1994 report, which underscores the impact poverty has on the deterioration of child health. They may also use the statistics provided in the Campaign 2000 annual report card, which also makes the link between low levels of income and their impact on the health of families living in poverty. I've brought a few copies of those for members who haven't seen it.
At the time it was created the welfare branch of Health Canada aimed to guarantee a basic level of income, of security, and wellness to needy families. It was placed in Health Canada because of its contribution to the health of those who benefited. Since its transfer to Human Resources Development, the funds allocated have been drastically reduced and the importance of those transfers and these reductions to the health of Canadians has not been taken into consideration.
Whether in a community or an institutional setting, pharmacists see, on a daily basis, the impact of economic conditions on the health and well-being of their patients. They often see patients unable to leave the hospital because they cannot afford medications for lack of supplemental insurance coverage or because the specific drugs are not covered under private or public benefit programs outside of hospitals.
The second factor that needs to be taken into consideration when really looking at the welfare component is the Canada health and social transfer, which was introduced in the 1995 federal budget by the Minister of Finance and which announced, once again, as a rationalization measure and in addition to drastic cuts to all the envelopes concerned, the creation of a single transfer to the provinces, which would include in one global amount the Canada Assistance Plan transfers, the equalization payments and the health care transfers.
Though the principles for these transfers have yet to be developed by the Minister of Human Resources Development, and the Department of Finance has not yet announced the exact way in which they will be made or how the cash component of the transfers will be maintained, the transfers are to come into effect in 1996.
In light of the fact that the National Forum on Health has yet to make recommendations, a final decision on the transfer of programs to the HRD would seem premature. Some of these recommendations will focus on the links between health and its determinants and on which social programs should be linked, if any, to the prevention of illness and health promotion mandates of the ministry.
Because of rapidly changing circumstances, including the work of the National Forum on Health and the Canada health and social transfer, the Canadian Pharmaceutical Association recommends that the transfer of welfare responsibilities from the Department of Health and Welfare, which took place in 1993, be re-evaluated.
We recommend that the health committee propose an amendment to Bill C-95 that would provide for a review of the decision to proceed with the transfer of responsibilities pending the final report of the National Forum on Health. Should the transfer of responsibilities be enacted as per Bill C-95, the health committee should propose an amendment to the bill to include a process of linkage between the appropriate authorities within each department and recommend means of establishing ongoing communications and a process for evaluation.
CPhA thanks you for this opportunity to share our views, which we hope will be taken into account in your deliberations.
The Chairman: Thank you very much, Ms Willems. I would now turn to our committee for their comments and questions, starting with Madame Picard.
[Translation]
Mrs. Picard (Drummond): Good afternoon and welcome to this committee. In your brief, you wrote this:
- CPhA feels it is its duty as a health care organization to raise some concerns about the separation
of social programs that impact directly or indirectly on health from the purview of the Minister
of Health.
We feel that the minister's responsibilities of safety and health promotion would be easier to fulfil with appropriate programs and adequate funding.
First of all, I would like you to specify what you mean by ``appropriate programs and adequate funding''.
.1545
Ms Willems: To answer your question, I need to go back in time. To us, it is quite clear that social insurance as it was originally established was meant to improve living conditions and health of recipients. It was not just a purely economic guaranteed minimum income, but a program to insure the well-being or the basic welfare of people.
After that component was transferred to Mr. Axworthy's department, funds have been cut, programs have been reduced, and, after 1998, with the proposed new transfer procedure, nothing will guarantee that the social programs transfer will be made normally.
It is obvious for us that those programs, which are preventive in nature, should not be included in measures that are directly linked with employment and the economic situation of people. They have an extra dimension, that of providing a certain guaranteed minimum income to recipients so they can have a healthy life, and not merely survive.
Mrs. Picard: Could you provide an example of a program which has been abolished?
Ms Willems: I can think of Brighter Futures, a program to improve living conditions of very young children. This program was within the purview of the Minister of Health, and what remains of it is still under the minister's responsibility. Brighter Futures was a kind of incubator to develop new social programs to help young people, give them better opportunities in the future, and help them become full-fledged citizens.
Mrs. Picard: You made recommendations concerning the National Forum on Health.
Ms Willems: Yes.
Mrs. Picard: You know that the provision of health care is an exclusive provincial jurisdiction, and you also know that provincial ministers do not participate in the forum.
You are also aware that most provinces are currently in the process of implementing reforms. What significance and consideration do you think they will give to the report and work of the forum?
Ms Willems: I think the forum - I know the situation is a bit different in Quebec, being a Quebecer myself. But the forum tries to renew the links between our shared values and health, whatever the province people happen to live in.
I also work for a coalition called HEAL that tries to find ways to keep part of the transfers. I know Quebec is not affected yet, but it is obvious to us that the forum activities should consolidate and reaffirm values shared by all Canadians, since 89% of them think that health or at least the health system is one of our most basic values.
Therefore, I think that recommendations will be made on the basis of general principles that will allow all provinces who so wish to have the same standards, or at least a level of health care that is relatively equal throughout Canada, and prevent balkanisation.
At this very moment, there are differences between provinces in the health system. We know that some provinces have decided to stop paying AIDS drugs, and some people are moving from one province to another because of that. I see a danger in this and I think the Forum mandate is precisely to try to set the basis of a system that will provide adequate health care to all Canadians.
Mrs. Picard: Thank you very much.
[English]
The Chairman: Thank you.
Dr. Hill.
Mr. Hill (Macleod): I'd like to talk briefly about the forum as well. You've placed quite a bit of emphasis on the forum, on waiting for its results before making these changes. Although Madame Picard and I don't agree on many things, we do agree on the ineffectiveness of the forum without the provincial responsibility there. Why do you put that much emphasis on this forum?
.1550
Ms Willems: Primarily because I don't see the elected officials doing the groundwork for the reform of the health care system that would be needed as a basis to re-examine and retool the Canadian health care system. I think it's unfortunate the provinces are not at the table. However, they were asked to nominate people from the provinces and some of them have done so.
The elected officials from the provinces are not at the table. But I know the deputy ministers, as well as the ministers of health, do have on their agenda as an information-sharing session, every time they meet, a look at what is the work of the forum.
I have to tell you the perception from the associations working in health is a little bit different from the perceptions on the Hill about the National Forum on Health. The work they have managed to accomplish within one year is quite extraordinary.
Mr. Hill: In terms of health care reform, let's just say now the forum comes down with specific recommendations that see the changes they expect. How would you see that changing Bill C-95, and the division of these powers?
Ms Willems: They're looking at the determinants of health. So I'm quite certain they will have to work with some economic component and social programs to be able to intertwine them in order to enact the prevention mandate of the Minister of Health, or the promotion of the health mandate of the Minister of Health. At this point in time, by severing this part of the welfare component, what we're actually doing is just giving to the Ministry of Health the money it needs to effect the transfer, and also basically the money it needs to ensure drug safety and a few other programs, but not much more. So to me the forum has a broader view of health and will not put health in a silo.
The Chairman: Thank you, Dr. Hill.
I now turn to Dr. Fry.
Ms Fry (Vancouver Centre): Thank you very much for your presentation. It is very heart-warming to see some people really see the forum for what it is. The work it is doing is, as you say, absolutely extraordinary.
I just wanted to pick up on your concern, which I think is a valid one, that what would happen by removing welfare would be a fragmentation of the whole issue of the determinants of health. While to an extent this is true, I think maybe the issue I would ask you about is whether the objective needs to change. You pointed out the forum is looking at the determinants of health, and we know one of the biggest determinants of health is poverty.
I don't see the objectives or the recommendations that would come out of the forum will necessarily be changed by this bill. The process through which we reach those objectives may shift, because if we look at everything affecting health and bring it under the mandate of Health, Health will become a super-ministry that occupies probably three-quarters of the whole government powers.
It therefore would make it ineffective. It would centralize everything. I think what one should be concerned about moving to, and I wondered if you had a comment on this, is whether or not we should be looking at a way of establishing formal linkages between Status of Women, DIAND, HRD, Environment, even Labour.
So there would be very formal linkages, because we know each one of them impacts on health. We would have these close working relationships in which we really and truly bring a holistic look at health. So in the end, environment will no longer, as a ministry, think of the environment per se as something to do with the economy, but will always be looking at the health component of it, and so on and so forth.
What do you think of that concept? It seems to me to be more workable in terms of achieving results, but there must be formal linkages. What do you think of it?
.1555
Ms Willems: I have two comments on that. First, Health would have to be a super-ministry, but isn't HRD one right now? Isn't the component of welfare and health lost in there?
Second, there is a blueprint for exactly those types of linkages that was developed in the 1970s and 1980s concerning the promotion of women within each department. Groups worked directly on aspects relating to women's issues in each of the departments, to make sure they were high and visible. In the early 1990s the same thing was done with environmental concerns.
I think the blueprints are there. The linkages have been loosened because of lack of money, personnel and so on, but I think they already exist if anybody wants to just dust them off.
Ms Fry: You made a comment about Brighter Futures. Brighter Futures is still under Health, it's just called by a different name now. These things haven't changed. I know Health spoke in this bill about the fact that it intends to broaden its mandate to look at the issues of promotion and prevention, public health and safety, and many of those things. It intends to look at promoting the health status, and I think formal linkages would be a good way of doing that.
If you consider poverty to be a major determinant of health, how do you deal with poverty? Some would say if 45% of heads of households currently on welfare now are employable, then the answer would be skills and training to help them to become employable. You would still have to link with HRD anyway to find a solution to some of the aspects of poverty. So I wonder if that is something you could see as being workable.
Ms Willems: Yes, but I also think palliative measures such as training and so on are not the end goal. Losing employment as part of HRD, or at least the component that was called employment and employment creation and labour, has really been felt by the community as a disinvolvement of the government in an area where it was really needed.
Ms Fry: Do you think those powers should be shifted to the provinces?
Ms Willems: I'm not sure whether there can be a coherent approach if we do it that way. We've seen a lot of jockeying for external markets, for example, from province to province. That will continue, creating differences in the provinces as well.
[Translation]
Mr. Patry (Pierrefonds - Dollard): Thank you very much for your presentation.
Since social security and social protection are not included in Bill C-95, I would like you to please elaborate on your third recommendation, concerning the linkage between the appropriate authorities within each department.
Secondly, do you think this bill is a step backward as far as the health of Canadians is concerned?
Ms Willems: I said a moment ago that the existing links and those that should be established should all be much stronger and steadier. They should be legislated rather than be left to the uncertainty of future regulation.
Now, is this bill a step backward? I would say yes, because I think, like most Canadians, that the health system is our most important tie in Canada. Any measure that cuts fund for programs we cherish and programs that may disappear under a different department is actually a step backwards. The federal government should really get involved in health care and put its money where it belongs.
Mr. Patry: Thank you, Mr. Chairman.
[English]
The Chairman: Mr. Szabo.
Mr. Szabo (Mississauga South): This is an interesting discussion. The first thing I thought of was dominoes.
I suppose if you wanted to carry on with the theme of your intervention, we should probably incorporate the Ministry of the Environment into Health as well because of the linkages. We should probably also put in Aboriginal Affairs because of the severe health issues in the aboriginal communities. Once you start moving on this, all of a sudden it's all in one spot.
.1600
I understand the principle you're talking about, but I think it may be too much to ask for everything to be totally colour-coded and slotted, independent and exclusive from every other department. There has to be some sort of overlap. Some cooperation has to exist.
Ms Willems: There has to be cooperation, but there hasn't been. I think this brief is trying to alert you to the fact that the process right now has been fairly disjointed. The review of social programs that has been undertaken by HRD has not really been done in conjunction with the National Forum on Health.
There are actually very few discussions between the people who are looking at that right now. There is a feeling that as government is getting out of business, it's getting out of many things quickly without making those links, and without looking at those them in a very serious fashion.
As far as your comment on the environment, I studied environmental law when I was younger. One of my thesis points was that there should always be a super-ministry of the environment to overview everything else. That was in the 1970s. We're now in the 1990s and the economic considerations are very different.
Mr. Szabo: I don't think I'd disagree with you. The idea of a sustainable development strategy is very important and in fact is part of the government's mandate.
The health forum is issuing periodic statements or reports, but its full work and the integrated package of its work isn't going to be reported on for probably another three years. Are you suggesting we just wait with bated breath to see what it has to say in its final report?
Ms Willems: No. Because it knows some of the work is crucial, such as the private-public funding, it's planning to have at least an interim report for March 1996. So a number of issues are being worked on in an accelerated fashion because it's aware of the economic considerations at play right now.
Mr. Szabo: Yes, but it's still an interim report and the work is ongoing.
Ms Willems: But there's still work that can be done according to that.
Mr. Szabo: Finally, on the health and social transfer, I glean from the gist of your notes that the reduction in the transfers to the provinces in the envelope of the Canada health and social transfer causes you some concern. Do you think the decision to combine the funding for the various envelopes into one block funding is going to penalize health initiatives at the provincial level?
Ms Willems: I think you probably will see that if it remains that way. We appeared before finance last week, when I was initially scheduled to appear here, to talk about the transfer and the fact that the funds for health should be earmarked. I think as the envelope gets reduced over the years you will see a lot more jockeying going on among social assistance, post-secondary education and health than you have. The push for the privatization of this sector will be greater. It will not fall on deaf ears.
Mr. Szabo: You're familiar with the mechanics of the tax points and the cash and how that works. If they were kept in separate envelopes, with one for the health transfer, and the tax points exceeded the amount and therefore the cash was zero, what impact would that have on the federal government's ability to protect and defend?
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Ms Willems: The federal government would no longer hold the stick.
Mr. Szabo: So having cash is an integral component?
Ms Willems: It's an integral component, which is why the HEAL brief - and I will make sure you get copies of it - was recommending that there be a $250-per-capita transfer to every province.
Mr. Szabo: Regardless of tax points?
Ms Willems: Yes.
Mr. Szabo: A spending increase.
Ms Willems: Yes.
Ms Fry: You actually answered the question about your brief with regard to cash.
I find it interesting that you would suggest that the transfer in itself, having been lumped into one block transfer, would have a negative impact, given what you've said earlier in your brief about the close linkages between health, social services, and poverty. I wondered whether you had a comment on this. It means that by pulling them together, one, you keep a cash component, the cash component that has come through on the social services transfer, which will always be cash, which is now going to be sunsetting in terms of points, so that keeps your cash in the block.
The fact is, in the transfer of payments originally in the EPF there were no strings attached, except what is still attached, which is the Canada Health Act and the five principles in medicare. So nothing really has changed. All you've done is not only injected cash through the social services but also allowed for health to be broadened in terms of the social service impact of health.
Again, I'm sure you would agree that there are substantial savings to be made in the delivery services at this point in time, which could then be rolled over, whenever possible, into the health promotion and prevention aspects that the social services envelope would require. It seems to me that this is a progressive way in which to go.
What do you think? What is your comment?
Ms Willems: From previous experience with transfers that were not earmarked - we saw, for example, what happened in your home province of B.C. with post-secondary education money that went to road construction - I think the danger is that, yes, for the time being there is still some cash component; however, with the reductions that are ongoing and will continue to be ongoing, there's a real danger that they will disappear.
Ms Fry: But this is presumption.
Ms Willems: Well, no. If you read the CHST -
Ms Fry: I have.
Ms Willems: - as it was established, it gives provisions for this until -
Ms Fry: It's a two-year program at the moment.
Ms Willems: - 1998 -
Ms Fry: Yes.
Ms Willems: - and it doesn't say what happens to it afterwards.
Ms Fry: Then you're presuming that it's going to keep getting smaller, but it might not be so.
The Chairman: I would like to question on the opportunity, particularly the opportunity to respond to the suggestion by HEAL for the $250-per-capita transfer, independent of sort of an interest in the equalization function that was performed by the transfer, which would be inconsistent with the per-capita transfer -
Ms Willems: But which Ontario would really like.
The Chairman: I'm absolutely certain.
Independently of that, though - What I'm saying is I won't try to make that point, but I will put this question.
All the literature when EPF was first established and most of the subsequent debate suggest that essentially the transfer is spending power. It is designed almost singularly to allow the federal government to establish some national purpose and enforce it. The equalization function basically came after the fact.
.1610
Is it not the case that the spending-power application would be different by jurisdiction, in that each jurisdiction would have the capacity to tell the federal government they're not interested in their money at different levels? Is that not true?
Ms Willems: They could say that, but I don't know which province would do that.
The Chairman: I guess what I'm saying is they certainly wouldn't all do it at the same time. There would be a point at which some provinces would be able to say that and some provinces would be less able to say that.
Ms Willems: I guess I'm just reminded of human nature and what happened with the transfers on training that were proposed yesterday by Prime Minister Chrétien and how they were received in the west as too much for central Canada. Ideally, yes, if we had reasonable people at all levels, that's the way it would work. Reality indicates that may not be the case.
The Chairman: The other point I would make speaks more to the question put by Dr. Hill. In the case of the representative on the National Forum on Health from the province of New Brunswick, the gentleman also happened to be the previous executive director of the premier's council on devising a new health strategy. You don't have to mark it in stone to have that kind of cooperation; sometimes you just get it because it makes sense.
If there are no further questions, we thank you very much not only for your appearance but also for your patience with this process. I spoke with the witness Friday and I wouldn't have wanted to have to get ready myself, so I appreciate it very much. On behalf of all members of the committee, we appreciate the fact that you've been able to get this together and to be here with us today.
Ms Willems: It makes for interesting weekends. Thank you very much.
The Chairman: I'd like everyone to stay for a few moments so we can deal with a little bit of business as the witness departs.
Specifically, as you recall, the Canadian Nurses Association suggested that they were interested in appearing as well. I've had an opportunity to talk with the association and they have provided a brief. That brief arrived today. It is being translated and it will be made available to members tomorrow.
I understand also from Madame Picard that there are no further witnesses who intend to appear. So with that, I would ask for your concurrence that we proceed on Thursday with clause by clause. I would ask members who have amendments that they would like considered to get them to staff tomorrow so we can begin the process of getting ready for that exercise.
I would take direction as to whether we would proceed as early as 10 a.m. on Thursday. We had set aside 3:30 p.m., but if we wanted to we could do it as early as 10 a.m., if we're in agreement. Does anyone have any difficulty with 10 a.m. on Thursday?
[Translation]
Mrs Picard: I agree, but I should tell you I cannot be here on Thursday afternoon. Is the meeting on Thursday morning?
[English]
The Chairman: Yes, if that's okay. The time we had set aside last week was later, but if we could proceed at 10 a.m. on Thursday I think that would be all the better.
Some hon. members: Agreed.
The Chairman: I adjourn to the call of the chair. Thank you very much.