44 VOLUME 4 - storage.googleapis.comstorage.googleapis.com/cantookhub-media...the contexts in which people live (i.e. families, schools, work and communities), as well as on issues

Canada health Action: Building on the LegacyPapers commissioned by the National Forum on Health

V O L U M E 4

FORUM NATIONALSUR LA SANTÉ

NATIONAL FORUMON HEALTH

Striking a Balance

HEALTH CARE SYSTEMS IN CANADAAND ELSEWHERE

Striking a Balance

HEA

LTH

CA

RE SY

STEM

S IN C

AN

AD

A

AN

D ELSEW

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H ow can the health of Canadians be promoted across different age groups? What is the level of quality of Canada’s health care system?

On the international level, how do our health care costs compare with those of other countries? In February 1997, the National Forum on Health pre-sented its recommendations to the federal government on ways to improve the health system and the health of Canadians. To support its work, the Forum commissioned over forty research papers. These papers were written by the most eminent specialists and are brought together in the series Canada health Action: Building on the Legacy, which is comprised of five volumes:

Volume 1 – Children and Youth

Volume 2 – adultS and SeniorS

Volume 3 – SettinGS and iSSueS

Volume 4 – health Care SYSteMS in Canada and elSeWhere

Volume 5 – evidenCe and inforMation

The following papers are presented in volume 4:Geoffroy Scott – International Comparison of the Hospital SectorAstrid Brousselle – Controlling Health Expenditures: What MattersWendy Kennedy – Managing Pharmaceutical Expenditures: How Canada

ComparesCentre for International Statistics – Health Spending and Health Status:

An International ComparisonDamien Contandriopoulos – How Canada’s Health Care System

Compares with That of Other Countries: An OverviewDelphine Arweiler – International Comparisons of the Health ExpendituresMarc-André Fournier – The Impact of Health Care Infrastructures and

Human Resources on Health ExpendituresEllen Leibovich, Howard Bergman and François Béland – Health Care

Expenditures and the Aging Population in CanadaRaisa Deber and Bill Swan – Puzzling Issues in Health Care FinancingTerrence Sullivan – Commentary on Health Care Expenditures, Social

Spending and Health StatusAllan M. Maslove – National Goals and the Federal Role in Health CareRaiser Deber, Lutchmie Narine, Pat Baranek and Natasha Sharpe

– The Public-Private Mix in Health CareJohn Marriott and Ann L. Mable – Integrated Models: International

Trends and Implications for CanadaSteven G. Morgan – Issues for Canadian

Pharmaceutical Policyisbn 2-921146-51-7

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444

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Excerpt of the full publication

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CANADA HEALTH ACTION: BUILDING ON THE LEGACYPAPERS COMMISSIONED BY THE NATIONAL FORUM ON HEALTH



Striking a Balance

HEALTH CARE SYSTEMSIN CANADAAND ELSEWHERE

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CANADA HEALTH ACTION: BUILDING ON THE LEGACYPAPERS COMMISSIONED BY THE NATIONAL FORUM ON HEALTH



Striking a Balance

HEALTH CARE SYSTEMSIN CANADAAND ELSEWHERE

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Published by Éditions MultiMondes in co-operation with the National Forum on Health, Health Canada, and Canadian Government Publishing, Public Works and Government Services Canada.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior written permission of the Minister of Public Works and Government Services Canada.

Linguistic Revision: Traduction TandemProofreading: Traduction Tandem and Robert ParéCover Design: Gérard Beaudry Graphics: Emmanuel Gagnon

Volume 4: Health Care Systems in Canada and ElsewhereISBN 2-921146-51-7 Cat. No.: H21-126/6-4-1997ELegal Deposit– Bibliothèque nationale du Québec, 1998Legal Deposit – National Library of Canada, 1998© Her Majesty the Queen in Right of Canada, 1998

The series The National Forum on Health can be ordered at this address:Éditions MultiMondes930, rue PouliotSainte-Foy (Québec)G1V 3N9 CANADATelephone: (418) 651-3885; toll free in North America: 1 800 840-3029Fax: (418) 651 6822; toll free in North America: 1 888 303-5931E-mail: [email protected]: http://www.multim.com

In this publication the masculine form is used solely for ease of readability.

Canadian Cataloguing in Publication Data

Main entry under title: Canada Health Action: Building on the Legacy Issued also in French under title: La santé au Canada: un héritage à faire fructifier To be complete in 5 v. Includes bibliographical references. Contents: v. 1 Childen and Youth – v. 2. Adults and Seniors – v. 3. Settings and Issues – v. 4. Health Care Systems in Canada and Elsewhere. ISBN 2-921146-62-2 (set) ISBN 2-921146-51-7 (v. 4)1. Public health – Canada. 2. Medicine, Preventive – Canada. 3. Children – Health and hygiene – Canada. 4. Adulthood – Health and hygiene – Canada. 5. Aged – Health and hygiene – Canada. I. National Forum on Health (Canada).RA449.C28 1998 362.1’0971 C97-941659-0

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Foreword

In October 1994, the Prime Minister of Canada, The Right Honourable Jean Chrétien, launched the National Forum on Health to involve and inform Canadians and to advise the federal government on innovative ways to improve the health system and the health of Canada’s people. The Forum was set up as an advisory body with the Prime Minister as Chair, the federal Minister of Health as Vice Chair, and 24 volunteer members who contributed a wide range of knowledge founded on involvement in the health system as professionals, consumers and volunteers.

To fulfil their mandate, the Forum focused on long-term and systemic issues. They saw their task as formulating advice appropriate to the development of national policies, and divided the work into four key areas – Values, Striking a Balance, Determinants of Health, and Evidence-Based Decision Making.

The complete report of the National Forum on Health consists of two volumes: Canada Health Action: Building on the Legacy The Final Report of the National Forum on Healthand Canada Health Action: Building on the Legacy Synthesis Reports and Issues Papers

Copies available from: Publications Distribution Centre, Health Canada Communications, PL. 090124C, Brooke Claxton Building, Tunney’s Pasture, Ottawa, Ontario K1A 0K9. Telephone: (613) 954-5995. Fax: (613) 941-5366. (Aussi disponible en français.)

The Forum based its recommendations on 42 research papers written by the most eminent specialists in the field. The papers are brought together in a five-volume series:

Volume 1 – Children and YouthVolume 2 – Adults and SeniorsVolume 3 – Settings and IssuesVolume 4 – Health Care Systems in Canada and ElsewhereVolume 5 – Evidence and InformationIndividual volumes or the complete series can be ordered from: Editions

MultiMondes, 930, rue Pouliot, Sainte-Foy (Québec) G1V 3N9. Telephone: 1 800 840-3029. Fax: 1 888 303-5931. (Aussi disponible en français.)

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viii Canada health aCtion: Building on the legacy

Values

The Values working group sought to understand the values and principles that Canadians hold about health and health care, so that the system continues to reflect and respond to these values. To explore Canadian core values that are connected to the health care system and to understand the implications for decision making, the group conducted some original public opinion research, using scenarios or short stories which addressed many of the issues being investigated by the other working groups of the Forum. The scenarios were tested in focus groups. Quantitative research supplemented the focus groups making the findings more generalizable. The group also contributed to a review of public opinion research on health and social policy. Finally, a review of Canadian and international experience with ethics bodies was commissioned to identify the contribution that such groups can make to continuing the discusssion of values in decision making.

Striking a Balance

The Striking a Balance working group considered how to allocate society’s limited resources to best protect, restore and promote the health of Canadians. Attention was given to the balance of resources within the health sector and other sectors of the economy. The group commissioned a series of papers to assist in their deliberations. They conducted a thorough review of international trends in health expenditures, use of resources, and outcomes. They paid considerable attention to public and private financing issues, health system oganization and federal-provicial transfers. The group produced a separate discussion paper on public and private financing, and a position paper on the Canada Health and Social Transfer.

determinants of Health

The Determinants of Health working group sought to answer the question: In these times of economic and social hardship, what actions must be taken to allow Canadians to continue to enjoy a long life and, if possible, to increase their health status? The group consulted specialists to assist in identifying appropriate actions on the non-medical determinants of health. Specialists were asked to prepare papers on issues of concern to the health of the population related to the macro-economic environment, the contexts in which people live (i.e. families, schools, work and communities), as well as on issues of concern to people’s health at different life stages. Each paper presents a review of the literature, examples of success stories or failures, and relevant policy implications.

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ixForeword

evidence-Based decision Making

The working group on Evidence-Based Decision Making considered how individually practioners and policy makers can have access to, and utilize the best available evidence in making decisions. The group held two workshops with leading authorities to discuss how health information can be used to support and encourage a culture of evicence-based decision making, and to consider what information Canadians need to be better health care consumers and how to get that information to them. The group commissioned papers to: examine the meaning and concepts of evidence and evidence-based decision making as well as cases that illustrate opportunities for improvement; identify the health information infrastructure needed to support evidence-based decision making; examine tools which support more effective health care decision making; and identify strategies for assisting and increasing the role of Canadians in decision making in health and health care.

Members

William R.C. Blundell, B.A.Sc. (Ont.) Margaret McDonald, R.N. (NWT)Richard Cashin, LL.B. (Nfld.) Eric M. Maldoff, LL.B. (Que.)André-Pierre Contandriopoulos, Ph.D. (Que.) Louise Nadeau, Ph.D. (Que.)Randy Dickinson (N.B.) Tom W. Noseworthy, M.D. (Alta.)Madeleine Dion Stout, M.A. (Ont.) Shanthi Radcliffe, M.A. (Ont.)Robert G. Evans, Ph.D. (B.C.) Marc Renaud, Ph.D. (Que.)Karen Gainer, LL.B. (Alta.) Judith A. Ritchie, Ph.D. (N.S.)Debbie L. Good, C.A. (PEI) Noralou P. Roos, Ph.D. (Man.)Nuala Kenny, M.D. (N.S.) Duncan Sinclair, Ph.D. (Ont.)Richard Lessard, M.D. (Que.) Lynn Smith, LL.B., Q.C. (B.C.)Steven Lewis (Sask.) Mamoru Watanabe, M.D. (Alta.)Gerry M. Lougheed Jr. (Ont.) Roberta Way-Clark, M.A. (N.S.)

Secretary and deputy Minister, Health Canada

Michèle S. Jean

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x Canada health aCtion: Building on the legacy

Secretariat Staff

Executive DirectorMarie E. FortierJoyce Adubofuor Lucie LacombeLori Alma Johanne LeBelRachel Bénard Elizabeth LynamKathy Bunka Krista LockeBarbara Campbell John MarriottMarlene Campeau Maryse PesantCarmen Connolly Marcel SaulnierLise Corbett Liliane SauvéJohn Dossetor Linda St-AmourKayla Estrin Judith St-PierreRhonda Ferderber Nancy SwainsonAnnie Gauvin Catherine SwiftPatricia Giesler Josée VilleneuveSylvie Guilbault Tim WeirJanice Hopkins Lynn Westaff

We extend our sincere thanks to all those who participated in the various produc-tion stages of this series of publications.

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TaBle oF ConTenTS – VoluMe 4

HEaltH CarE FinanCing

InternAtIonAL CompArIson of tHe HospItAL seCtor ...................3

geoffroy Scott

Description of the Main Methods of Hospital Payment .....................................7Comparative Analysis of Acute Care Hospitals ...................................................7Summary and Conclusion ................................................................................22

ControLLIng HeALtH expendItures: WHAt mAtters ...................33

astrid Brousselle

Introduction .....................................................................................................39Change in Expenditures in 13 OECD Countries .............................................40Explanation of the Deviation in Health Expenditures from the Average of the Thirteen Countries Studied ....................................................................43Conclusion .......................................................................................................51

mAnAgIng pHArmACeutICAL expendItures: HoW CAnAdA CompAres ..............................................................................85

Wendy Kennedy

Methodology ....................................................................................................90Cross-Country Comparison of Per Capita Pharmaceutical Expenditures ............91Cross-Country Comparison of Drug Expenditures as a Percentage of Total Health Expenditures ............................................................................91Cross-Country Comparison of Pharmaceutical Expenditures as a Percentage of GDP .........................................................................................93Cross-Country Comparison of the Relationship of Pharmaceutical Expenditures to Wealth.....................................................................................94Cross-Country Comparison of Drug Use .........................................................96Cross-Country Comparison of Drug Sector Structures ....................................97Cross-Country Comparison of Health Indices .................................................97Discussion.........................................................................................................98

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xii Canada health aCtion: Building on the legacy

HeALtH spendIng And HeALtH stAtus: An InternAtIonAL CompArIson ...........................................................153

Centre for international Statistics

Health Care Spending among OECD Countries ...........................................157The Relationship between Health Spending and Health Status ......................157Other Forms of Social Spending that May Influence Health Status ................162Trends over Time ............................................................................................166Conclusion .....................................................................................................168

HoW CAnAdA’s HeALtH CAre system CompAres WItH tHAt of otHer CountrIes: An overvIeW .........................................173

Damien Contandriopoulos

Descriptive Analysis of the Various Health Care Systems ...............................177State of Health, Cost Control, and Performance of System ........................... 186Conclusion .....................................................................................................189

InternAtIonAL CompArIsons of HeALtH expendItures ...........213

Delphine arweiler

The Different Measurements of Health Expenditures ....................................217Prices and Quantities ......................................................................................225Conclusion .....................................................................................................236

tHe ImpACt of HeALtH CAre InfrAstruCtures And HumAn resourCes on HeALtH expendItures ................................253

Marc-andré Fournier

Introduction ...................................................................................................257Breakdown of Expenditures and Resource Configurations .............................258Configurations of Countries Successful and Unsuccessful in Controlling Expenditures ......................................................................... 275Conclusion .....................................................................................................282

HeALtH CAre expendItures And tHe AgIng popuLAtIon In CAnAdA ......................................................................................................285

Ellen leibovich, Howard Bergman, and François Béland

Introduction ...................................................................................................288The Aging Population and the Cost of Health Care in Canada ......................288

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xiiitable of Contents – Volume 4

System of Care for the Elderly in Sweden and the United Kingdom ..............296Care of the Elderly in Canada .........................................................................299Strategy for the Development of a System of Care for the Frail Elderly in Canada ...........................................................................................300Conclusion .....................................................................................................302

puzzLIng Issues In HeALtH CAre fInAnCIng ...................................307

raisa Deber and Bill Swan

Question One: Introduction and Summary ..................................................310Overview of Data ..........................................................................................310Hypotheses ....................................................................................................311Discussion ......................................................................................................329Question Two (Supplementary Question): The Case of the United Kingdom .....................................................................................331Conclusions ...................................................................................................335

CommentAry on HeALtH CAre expendItures, soCIAL spendIng And HeALtH stAtus ...............................................................343

terrence Sullivan

Introduction ...................................................................................................346Overview of the Data......................................................................................346Hypotheses .....................................................................................................347Conclusions ....................................................................................................352

intErnational CoMPariSonS

nAtIonAL goALs And tHe federAL roLe In HeALtH CAre ..........367

allan M. Maslove

Introduction ...................................................................................................371National and Provincial Goals in Health Care ................................................372Federal Levers in Health Care .........................................................................380National Goals and Federal Instruments: Options for Upholding National Health Care Principles .....................................................................384Models of Financial Partnership .....................................................................391Conclusion .....................................................................................................398

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xiv Canada health aCtion: Building on the legacy

tHe puBLIC-prIvAte mIx In HeALtH CAre ...........................................423

raisa Deber, lutchmie narine, Pat Baranek, natasha Sharpe, Katya Masnyk Duvalko, randi Zlotnik-Shaul, Peter Coyte, george Pink, Paul Williams

Objectives .......................................................................................................431Understanding the Basis for the Current Public-Private Mix of Services ..........431Legislative and Regulatory Framework ...........................................................457The Case of Canada: Selected Data on the Extent of the Public-Private Mix ....................................................................................469Case studies of Some Experiences with Different Models ...............................485Evaluating the Models: Equity, Efficiency, Security and Liberty .....................503Frameworks for Making Decisions about What Should and What Should Not Be Insured .........................................................................512Policy Implications and Recommendations ....................................................531

IntegrAted modeLs. InternAtIonAL trends And ImpLICAtIons for CAnAdA ......................................................................547

John Marriott and ann l. Mable

Introduction ...................................................................................................551Overviews of Systems in Selected Countries ...................................................558Overview of the Canadian Health System and Models ...................................609Key Features of Integrated Models ..................................................................626Key Features of Integrated Models in the Canadian Context ..........................640Evaluation of Integrated Models .....................................................................662Conclusions and Observations .......................................................................669

Issues for CAnAdIAn pHArmACeutICAL poLICy ..............................677

Steven g. Morgan

Introduction ...................................................................................................681The Economics and Politics of the Pharmaceutical Industry ..........................688Industry Trends and Corporate Strategies .......................................................699Strategies for Managing Benefits .....................................................................707Conclusion .....................................................................................................730

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Health Care Financing

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International Comparison of the Hospital Sector

Geoffroy Scott

Doctorate Student in Public Health University of Montreal

Summary

The health care system, and more specifically, the hospital sector, is at a crossroads. Numerous budget cutbacks in recent years have raised questions about the optimum allocation of resources in this sector.The National Forum on Health, through its “Striking a Balance” working group, is interested in this issue and believes that the public should be informed about the options. The primary purpose of international comparisons is to determine the relative ranking of the countries in order to provide an accurate and clear estimate of the resources invested in the sectors concerned. Using the most recent data available from the OECD, the comparative analysis presented in this report looks at some of the current trends in the hospital sector in the OECD countries studied.It should be noted that there may be certain imperfections in the results of these international comparisons and consequently, they should be used with caution. The statistical data contains certain biases and it is imperative that the reader take note of them (this issue is addressed in the description of the methodology).This comparative analysis tries to answer four key questions:

• Internationally,haveacutecarehospitalsexperiencedadecreaseintheirshareoftotalhealthexpenditures?

• Whatcomponentsofthehealthsectorhaveexperiencedanincreaseintheirshareoftotalhealthexpenditures?

• Dothewealthiercountriesspendproportionatelymoreonacutecarehospitalsthanothercountries?

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4 Canada HealtH aCtion – Health Systems in Canada and elsewhere

• Doesthequantityofphysicalresourceshaveanimpactontheuseofacutecarehospitals?This report begins with a short description of the methods of hospital payment

within OECD countries in order to help the reader better understand the various interactions between the utilization of hospital resources and hospital financing.

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Table of ConTenTS

Description of the Main Methods of Hospital Payment ..........................7

Comparative Analysis of Acute Care Hospitals ........................................7

Internationally, have acute care hospitals experienced a decrease in their share of total health expenditures? .............................................7

Which components of the health sector have experienced an increase in their share of total health expenditures? .........................13

Do the wealthier countries spend relatively more on acute care hospitals than other countries? ......................................................17

Does the quantity of physical resources have an impact on the use of acute care hospitals? ........................................................19

Summary and Conclusion ......................................................................22

Bibliography .............................................................................................24

AppendICeS

Appendix 1 Glossary ......................................................................... 27

Appendix 2 Methodology .................................................................. 29

Appendix 3 Statistical Calculations .................................................... 30

LISt of fIgureS

Figure 1 Acute care hospital expenditures/Total health expenditures..............................................................................9

Figure 2 Acute care hospitals—Number of beds per 1,000 inhabitants ..............................................................10

Figure 3 Resources (personnel) available per occupied bed (all hospitals except psychiatric hospitals) ...............................11

Figure 4 Density (number of nurses) per 1,000 inhabitants .................12

Figure 5 Hospital expenditures/Total health expenditures ....................14

Figure 6 Ambulatory care expenditures/Total health expenditures .......15

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6 Canada HealtH aCtion – Health Care Systems in Canada and elsewhere

Figure 7 Pharmaceutical goods expenditures/Total health expenditures............................................................................16

Figure 8 Other expenditures/Total health expenditures ........................16

Figure 9 Hospital expenditures/GDP ...................................................18

Figure 10 Acute care hospital expenditures/GDP ...................................19

Figure 11 Correlation between admission rate and number of beds per 1,000 inhabitants ..............................................................20

Figure 12 Correlation between length of stay and number of beds per 1,000 inhabitants ..............................................................21

Figure 13 Correlation between occupancy rate and number of beds per 1,000 inhabitants ..............................................................22

tAbLe

Table 1 Main methods of hospital payment in OECD countries ............8

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Canada health Action: Building on the LegacyPapers commissioned by the National Forum on Health

V O L U M E 4



Striking a Balance

HEALTH CARE SYSTEMS IN CANADAAND ELSEWHERE

Striking a Balance

HEA

LTH

CA

RE SY

STEM

S IN C

AN

AD

A

AN

D ELSEW

HER

E



H ow can the health of Canadians be promoted across different age groups? What is the level of quality of Canada’s health care system?

On the international level, how do our health care costs compare with those of other countries? In February 1997, the National Forum on Health pre-sented its recommendations to the federal government on ways to improve the health system and the health of Canadians. To support its work, the Forum commissioned over forty research papers. These papers were written by the most eminent specialists and are brought together in the series Canada health Action: Building on the Legacy, which is comprised of five volumes:

Volume 1 – Children and Youth

Volume 2 – adultS and SeniorS

Volume 3 – SettinGS and iSSueS

Volume 4 – health Care SYSteMS in Canada and elSeWhere

Volume 5 – evidenCe and inforMation

The following papers are presented in volume 4:Geoffroy Scott – International Comparison of the Hospital SectorAstrid Brousselle – Controlling Health Expenditures: What MattersWendy Kennedy – Managing Pharmaceutical Expenditures: How Canada

ComparesCentre for International Statistics – Health Spending and Health Status:

An International ComparisonDamien Contandriopoulos – How Canada’s Health Care System

Compares with That of Other Countries: An OverviewDelphine Arweiler – International Comparisons of the Health ExpendituresMarc-André Fournier – The Impact of Health Care Infrastructures and

Human Resources on Health ExpendituresEllen Leibovich, Howard Bergman and François Béland – Health Care

Expenditures and the Aging Population in CanadaRaisa Deber and Bill Swan – Puzzling Issues in Health Care FinancingTerrence Sullivan – Commentary on Health Care Expenditures, Social

Spending and Health StatusAllan M. Maslove – National Goals and the Federal Role in Health CareRaiser Deber, Lutchmie Narine, Pat Baranek and Natasha Sharpe

– The Public-Private Mix in Health CareJohn Marriott and Ann L. Mable – Integrated Models: International

Trends and Implications for CanadaSteven G. Morgan – Issues for Canadian

Pharmaceutical Policyisbn 2-921146-51-7

,!7IC9C1-begfbh!

444

Sans titre-7 1 11/04/08 10:23:46


Documents

44 VOLUME 4 - storage.googleapis.comstorage.googleapis.com/cantookhub-media...the contexts in which people live (i.e. families, schools, work and communities), as well as on issues