Where is the Evidence? : National Health Policy in the 21st Century
Speaking Notes
for
Alan Nymark
Associate Deputy Minister of Health
4th Annual HEALnet Conference
Calgary, March 28, 1999
Check against delivery
Introduction
Thank-you Kathryn; let me add my congratulations to Ron Yamada for his stewardship of the first
four years of HEALnet and extend best wishes for the years ahead.
I am pleased to be with you today, and would like to thank-you for your invitation to participate
in the 4th annual HEALnet conference. Your conference theme Putting Health
Research to Work is timely as we approach the challenges of the 21st century.
As emphasized in your strategic plan, a first step in Putting Health Research to Work is
recognizing the breadth of health research and its relevance for a wide range of decision makers.
Health research generates new insights into human biology and disease processes. It leads to the
discovery of new cures, medical technologies and procedures, and helps us tailor the health care
system to meet the needs of Canadians. It also helps us understand, and act on factors outside the
health care system, that affect the health of people and their communities.
Health research informs a wide range of decisions. Health system managers grapple with decisions
about the structure of service delivery. Clinicians confront daily decisions about treatment options.
Policy makers, at all levels, make decisions affecting the health of citizens in their jurisdictions.
As health consumers, we all make decisions affecting our personal health and that of our families.
These decisions are influenced by how we collectively "put health research to work." For example:
Are we asking the right questions? Involving the necessary people? Using the appropriate methods?
Are we reporting the results of our research in a manner that is meaningful and useful? And, are
we harnessing technology to optimize how results are shared and communicated?
In terms of your theme Putting Health Research to Work, I commend HEALnet
for your commitment to promoting evidence-based decision making in the workplace and throughout the
health system, whether it is in clinical practice, service delivery or policy development. You've
asked me to speak today about the use of evidence in policy development and have suggested an interesting
title, Where is the Evidence? : National Health Policy in the 21st Century.
Looking Back
Before looking ahead, I believe it's important to take a moment to look back. This will help us
see our national policy environment in a historical context and help us examine our current policies
in light of the evidence that was available when they were established.
Of course, the cornerstone of Canadian health policy is the Canada Health Act. Established
in 1984, the Canada Health Act reflected the views that had prevailed from the time of the
Medical Care Insurance Act in 1966; namely that health status is linked to the availability of health
care services. What did health care mean thirty years ago?? In two words: hospitals and doctors.
As a result, Canada's Health Act legislated that physician services and hospital-based care be publicly
provided. It also legislated that services be delivered according to five basic principles: universality,
accessibility, comprehensiveness, portability and public administration.
While the importance of these principles hasn't changed, our understanding of health and what determines
health, has evolved. In the 1970's, the World Health Assembly adopted the now all familiar, Health
for All by the Year 2000 Strategy. This strategy called on countries to take comprehensive action
to improve the health of all their citizens. Canada has been at the forefront of this endeavour with
the release of internationally acclaimed policy documents.
First there was A New Perspective on the Health of Canadians. Released in 1974, A New
Perspective was based on a growing body of research on the effects of behavioural factors
on health. Consequently, it pointed out that in addition to health care, health status is linked
to three other factors or "fields." These were identified as lifestyle, human biology and the environment.
This was followed in 1986 by Achieving Health for All: A Framework for Health Promotion which
outlined strategies for acting on the factors that influence health. Achieving Health For All called
for an increased emphasis on prevention, including activities which could be undertaken by individuals
and community agencies as well as by the health care system.
The most recent document, Investing in the Health of Canadians : Strategies for Population Health was
released in 1994 by the Federal, Provincial, Territorial Advisory Committee on Population Health. Strategies
for Population Health expanded on the earlier health field concept and identified seven key
influences or "determinants"of health. Of these determinants, it focussed the spotlight on the socioeconomic
environment and the impacts of peoples' living and working conditions on their health.
The impetus for Strategies for Population Health came from the field of population health research.
I understand that population health researchers are well represented on HEALnet and that the Institute
for Work and Health, for example, is a member organization. Your mission statement also recognizes
the relationship of the work environment to health and calls for evidence-based decision making in
the workplace as well as the health system.
While there are many explanations as to why the allocation of health expenditures has not kept pace
with this evolution in thinking on "why Canadians are healthy", surely the lack of consistent and
compelling evidence laid out in a way that the Canadian public might understand and make better choices,
is at the heart of the matter.
The Current Reality
Just as our view of health has evolved, so has the nature of our health care services. Over the
past few years, the circle of health care providers has widened to include a range of caregivers.
Instead of only hospitals or physicians, patients now go to a number of places: the community clinic,
the rehab centre, the long term care facility. New technology means care is often on an outpatient
basis, or even at home. New pharmaceuticals replace previously intrusive surgical procedures. New,
less intrusive surgical procedures mean that hospital stays are shorter and much of the convalescent
care is provided at home. In many cases, this has placed an increasing strain on informal caregivers,
many of whom are women.
However, while the nature of health care has been broadened, the funding model by and large, has
not. As a result, Canadians have begun to ask questions about the current mix of service and funding
arrangements. For example: "If so much of the care is provided outside the hospital and by a range
of caregivers, how are these costs to be covered? And, if care is given outside the hospital, how
can we ensure that these services will be there when they are needed?"
Even the conventional funding for hospitals and physicians has come under pressure. The financial
pressures of the 90's forced governments to not just slow the growth in funding, but to cut back
funding to some extent. As a result, Canadians have become worried about the future of health care.
They worry about waiting hours in an emergency room; about waiting months to see a specialist; or
about waiting a year for a long-term bed.
These fears threaten the foundation of our health care system, which is based on a bargain between
Canadians and their government. The terms of the bargain are straightforward. Canadians will support
a public health care system in exchange for a commitment that governments will ensure access to timely
and quality medically necessary services when needed.
So, that is the state of affairs we face as we stand on the threshold of the 21st century.
The complexity of the challenge means that merely spending more money is not enough. We will have
to be strategic to achieve the changes we need. We need policies based on evidence that is available
today, not 30 years ago. And when the evidence is not available we will need to build the evidence,
and the associated analytical capacity. We will also need a policy framework that uses evidence to
effectively make decisions. This policy framework will have to look at the health system as a whole.
Our Future Policy Vision
In looking ahead, let me begin by sharing some key elements of our policy vision for a renewed health
system. Would it still be based on the basic principles of the Canada Health Act?? The answer
is a resounding YES! While the evidence suggests that changes are needed to improve the relevance
and quality of the system, it does not suggest that changes are needed to the fundamental principles.
Quite the contrary, the evidence shows there is nothing superior to a single/payer, universal system
of health care for medically-necessary services. None of the alternatives compare to Canadian standards
for fairness. Nor are they more economical or efficient.
So, our efforts to renew the health system must safeguard the underlying principles of the Canada
Health Act. Canadians must have equal and timely access to quality care. And, accessibility
must be based on need, not the ability to pay. People should not have to buy their way to the front
of the line. In this area, we're doing quite well. The Report on the Health of Canadians shows
that despite recent financial cut-backs, access to insured medical services remains largely unrelated
to income.
In addition to being universally accessible, we believe a renewed health system must have four other
important characteristics. A renewed health must be flexible. It must be sustainable. It must be
integrated. And, it must be accountable.
First, a renewed health system must be flexible. It must encourage innovation that
will lead to improvements in service delivery. It must also be able to incorporate these improvements
into its delivery structures.
Secondly, a renewed health system must be sustainable. Canadians place a high value
on securing a healthy future for their children. This means creating healthy living and working conditions.
It also means ensuring that our health system will not "run out of steam." Canadians want to be sure
the health system is based on funding mechanisms that will guarantee it will be there for future
generations.
Thirdly, a renewed health system must be integrated. Recent developments have often
left the health care system fragmented. The health care system does not provide an integrated approach
for patients to move from one health care provider or system to another. Rather, it favours a fragmented
approach to service delivery. The stories are all too familiar. Patients receive drugs while in hospital,
but pay out of pocket when they are at home. When they leave the hospital they frequently cannot
find the home or community services they need. Or, if they find them, they can't afford them. In
fact, the Report on the Health of Canadians shows that access to medical services outside
the insured system is seriously restricted for many Canadians.
What would an integrated system look like? An integrated system would be evidence-based, and would
encompass the entire health continuum: from health promotion and disease prevention; to early detection
and diagnosis; to treatment and care. The full range of services would be properly funded and closely
connected. In an integrated system, public coverage would follow care; from primary care, to the
hospital bed, to home care, and to long-term care facilities. There would be a smooth transition
from one service provider to another. Funding would be based on the patient's needs, not the building
in which the service is provided, or the person who happens to provide it.
Finally, a renewed health system must be accountable. Equal and timely access to
quality care requires a system that is accountable. This will mean gathering and sharing information
about outcomes; about which treatments work best and which management practices are the most successful.
Here, I'm sorry to say, the health sector is behind. As a result, I believe this is an area where
we must put "health research to work". Our research efforts must help us find the appropriate means
for analysing and reporting information so we can ensure the health system is fully accountable to
Canadians. Accountability starts with showing that health practices work, but it must also address
which practices work best. Indeed, ultimately, it must address whether the dollars we now spend could
not be better spent to deliver better health.
Translating our Vision into Reality
This vision of a renewed health system is not new. The National Forum on Health, on which some of
you served, called for an integrated, accountable health system. And, standing here today, I believe
we've made important strides during the past year in translating this vision into reality. These
strides have been about partnership and investments.
A Renewed Health Partnership
Last September, the Health Ministers from all ten provinces and two territories agreed on directions
and priorities, including integrating services and developing home care and continuing care. The
agreement also emphasised the importance of promoting the effective use of information and reporting
systems.
More recently, in the context of the social union negotiations, the provincial and territorial governments
re-committed themselves to the five principles of the Canada Health Act. They also agreed
to dedicate all increases in federal health transfers to the health care system. Spending increases
would be used to make health care as effective as possible and to provide information about health
and the health system to Canadians.
Increasing our investments
The measures announced in the recent federal budget will allow us to pursue the directions agreed
upon by Canada's Health Ministers. The budget's health investment of $12.9 billion dollars over the
next three years constitutes the single largest new investment this government has ever made. It
clearly confirms that the health of Canadians is among the Government's highest priorities.
In addition to increased transfers to provinces and territories, the budget will inject $1.4 billion,
over three years, into a number of key areas. I would like to focus on two areas which are particularly
relevant to your theme Putting Health Research to Work.
The first investment is in the area of Health Research and Innovation. Funding of $550 million over
the remainder of 1998-99 and the following three fiscal years for new health research initiatives
announced in the 1999 Budget will provide significant new federal resources for health research and
help transform the way in which Canadian health research is governed, funded and conducted, to better
meet the health needs of Canadians.
Budget 1999 recognized that effective health research is essential if we're serious about revitalizing
our health care system and working collectively to improve the health of Canadians. And, like our
health delivery system, the investments we make will pay off better if they are integrated. As a
result, the Government plans to establish a pan-Canadian network of Institutes of Health Research.
Some of you here today deserve much of the credit for moving this project forward and I would like
to thank you for your efforts.
Dr. Henry Friesen, Chair of the Medical Research Council, has agreed to serve as the Chair of the
Interim Governing Council during the transition period which we plan to have completed by next spring.
The Institutes will be structured along subject lines and will coordinate multi-disciplinary research
across the country. Each Institute will cover the full spectrum of research, from molecules to communities,
and will provide talented investigators with the resources they need to address the health challenges
faced by Canadians. Funding increases will support both the establishment of Canadian Institutes
for Health Research (CIHR) and a greater overall research capacity.
In addition to funding for the Canadian Institutes for Health Research, health funding for federal
research councils and organizations will be increased. This will facilitate the involvement of researchers
in the CIHR and help the Institutes achieve their objectives.
The second investment in Health Knowledge Management is in the area of Health Information. On February
3rd of this year, the Minister's Advisory Council on Health Infostructure recommended that the health
lane of Canada's information highway be developed. Again, there are members of the Council here today.
The 1999 Federal Budget committed over $350 million over the remainder of 1998-99 and the following
three fiscal years to facilitate the health lane of the information highway. This investment will
help (1) generate appropriate data and analysis as the foundation for better evidence-based decision-
making; (2) it will encourage greater use of communications technology to improve health and health
care for Canadians; and it will enhance governments' accountability to Canadians for public spending
on health. This funding will be used as follows:
- The Canadian Institute for Health Information (CIHI) will lead a pan-Canadian, integrated effort
to improve data-gathering and information exchange. This will help ensure health care dollars are
spent wisely, and give Canadians access to accurate information on health matters.
- The Canadian Health Network will provide Canadians with "one-stop shopping" for credible, current
information on health promotion and disease prevention, self care, and the performance of the health
system.
- New funding will allow the National Health Surveillance Network to contribute further to public
health by expanding its capacity to gather and analyse health intelligence information - statistics
and facts related to health issues such as immunizable diseases, meningitis outbreaks and food
safety.
- A First Nations Health Information System will link some 600 First Nations communities and will
ensure their health information systems are also linked to national surveillance programs and provincial
systems.
- Steps will be taken to harness information technology in the delivery of health care by offering
renewed support to organizations engaged in such activities, and addressing issues related to security,
personal privacy, system compatibility and the legal and ethical questions associated with using
information technology in health care. Two of our priorities here will be to encourage telehealth/telecare/
homecare and to develop an electronic patient identification system in Canada.
- Finally, we will strengthen governments accountability to Canadians for health programs by, for
example, establishing and reporting on benchmarks and performance indicators, at all levels, and
publishing annual Health Canada reports in those areas of our responsibility.
Creating a Knowledge Base for Policy Making in the 21st Century
At this point, I'd like to return more directly to the title of my address, "Where is the Evidence;
National Health Policy in the 21st Century." We've talked about the need for a
broad policy framework that will encompass our actions to renew the health system while working
with others outside the system, to improve the health of Canadians. We've also spoken about the
strides that have been taken to strengthen the partnerships, break down the silos and secure the
investments that will be needed to realize this policy vision.
I'd now like to focus on another element which is critical... and that is evidence: namely, our
capacity to create, access and use the evidence that will be required. At the beginning of my remarks,
I reflected on the historical context of our policy environment and noted that previous documents
such as, A New Perspectives and Strategies for Population Health were based on
an evolving body of evidence about health and its determinants. To realize our policy vision for
the next century we must move forward from this evidence base. As the title of this address asks....where
is the evidence?
Because of the increasing breadth of the health field and its research enterprise, it is clear that
future policies will have to be based on evidence from a variety of sources; from biomedicine, epidemiology
and social science, to name only a few. The breadth of this research base poses many challenges for
decision makers. A key challenge is often the need for consolidated evidence from a variety of sources,
and even disciplines. On this front, there have been significant advances.
One example I'd like to highlight is the contribution of Canada's population health researchers
in synthesizing the evidence on the determinants of health. The book, Why Some People are Healthy
and Others are Not is a compelling synthesis, drawn from a variety of disciplines, on the multiple
and interactive factors that determine health status. To further the research on the determinants
of health, Health Canada has launched the Canadian Population Health Initiative in partnership with
Statistics Canada, the Canadian Institute for Health Information, and the Federal Provincial Territorial
Advisory Committee on Population Health.
More and more, research from biomedicine and the social sciences is beginning to mesh. This is creating
new opportunities for expanding our knowledge about the links between biological pathways and the
determinants of health. For example, exciting new research on brain formation has shed light on how
stimulation in a baby's environment interacts with biology to influence healthy child development
in earliest infancy.
In addition to recognizing the multidisciplinary nature of health research, I believe a few other
points are key if we're serious about applying evidence-based decision making in the policy realm:
- First, we need to recognize that knowledge is more than information and data. As Davenport and
Prusak have stated in their book "Working Knowledge"
"Knowledge is a fluid mix of framed experience, values, contextual information, and expert
insight that provides a framework for evaluating and incorporating new experience and information.
It originates in the minds of knowers."
- Second, we need to admit that policy making is a complex, dynamic and often confusing process.
It is a multi-staged activity: from identifying issues and conducting public consultations; to
developing policy options and agreeing on the option of choice; to communicating and implementing
our policy decisions; and finally, to evaluating the outcomes of our decisions. Each of these stages
requires knowledge, but what is considered "evidence," varies with the type of policy being developed,
and the stage in the policy making process.
- Third, I believe we need to acknowledge that a straightforward definition of evidence is difficult.
Given the scope of health research, evidence must be understood from a number of viewpoints and
disciplines. The standards for what is considered evidence in one area, need not be the same as
for another. For example, as certain stages in the policy process call for increasing use of consumer
consultations and qualitative research methods, it is clear that additional types of information
will need to be regarded as evidence. I see from HEALnet's strategic plan that two of your research
modules will explore the nature of evidence and it's use in decision making. We will look forward
to the results of your research in this area.
- Finally, we must recognize that health policies are value-based, as well as evidence-based.
Policy decisions, at all levels, are future oriented and involve citizens, organizations, and a
wide range of resources. As a result, health and health care decisions almost always have a subjective
component. I am pleased to see that your research agenda includes the development of decision making
models that will take this into account.
Moving Forward Together
Before closing, I would like to spend a few minutes on how the federal government intends to work
with others, like HEALnet, to develop an evidence-based policy agenda for the 21st century.
- First, it's important to have a clear policy vision for the future. This vision must be based
on values that are important to Canadians and on the best evidence that is currently available.
Such a vision must guide our actions to renew the health system, by ensuring it is flexible, sustainable,
integrated and accountable. It must also enable us to understand and act on the determinants of
health that lie outside the health care system. Federal, provincial and territorial governments
have made great progress over the last year, but it is time to re-invigorate that work and to engage
Canadians in building the most appropriate vision for health in the future.
- Second, we must continue to strengthen our capacity for integrated research. The CIHR is one
example, HEALnet is another. As part of the federal government's Network of Centres of Excellence
program, your network brings together researchers from university, government and private sector
organizations to address complex questions through multi-disciplinary research. Renewal of your
strategy is most welcome and we look forward to this next phase.
- Third, we must build stronger links between the research and policy domains. HEALnet's renewed
research agenda will focus on "the transfer and uptake of research in decision-making." This is
an important area for the federal government as well. One reason for this is the increasingly horizontal
nature of policy-making. This is particularly true for health, where policies from many sectors
can have an impact on peoples' health. In 1996, the federal government launched its Policy Research
Initiative which now involves over 20 departments. Its objective is to strengthen the government's
horizontal policy-research base by facilitating links between the policy and research communities.
- Fourth, we must establish a sustainable Health Infostructure. As outlined in the budget, we
plan to work with the Canadian Institute for Health Information and others, to create a national
information and communications network. Our vision is that Canada's Health Infoway will not be
a single structure. Rather, it will be built upon provincial, territorial and federal initiatives
already underway.
- Finally, we must improve our capacity to analyse health information and data. It's important
to understand that the Health Infostructure is about more than the use of technology to establish
information systems. It's about the type of health information the system can create. It's also
about increasing our capacity to share that information with decision makers; whether they be consumers,
clinicians, system managers or policy makers.
To help us do our part to address these challenges, Health Canada has recently established a new
Branch; the Information, Analysis and Connectivity Branch. This Branch will help the department create
the infostructure and conduct the analysis required to create a solid foundation of information about
the health care system and the health of Canadians.
I am pleased to see that HEALnet has also responded to this challenge by creating a third research
module devoted to issues of Performance. We will look forward to the performance indicators and assessment
tools that will result from this research module.
Conclusion
In closing, I would like to say how fortunate we are in Canada. On many indicators, Canadians enjoy
a standard of health that is among the best in the world. We also have one of the best, if not the
best, health care systems in the world. A system in which Canadians take pride, not just because
of the services provided, but because of the underlying principles on which it is based.
Yet, as we stand on the threshold of the 21st century, we can see that, despite our best
efforts, the Health for All goal has yet to be realized. Not all Canadians share in these overall
high standards of health. Nor is the health system flexible or integrated enough to meet Canadians'
evolving health care needs.
If we are to join with other countries in re-committing ourselves to WHO's Health for All challenge,
we must adopt a policy vision that will allow us to renew and modernize our health care system. At
the same time, it must direct our efforts to improve the health of Canadians by working on determinants
that lie outside the health system.
To translate this policy vision into reality we need strong partnerships, secure investments and
a solid evidence base. I would like to say, on behalf of the federal government and of Health Canada,
that we look forward to continued collaboration with organizations like HEALnet in "putting health
research to work." By working together we can secure the evidence that will be required to meet the
challenges of the 21st century.
Thank-you and best wishes in your deliberations.
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