By Bob Gardner and Emily Wong
The federal government’s decision to stop funding the Health Council of Canada as of March 2014 had prompted an outcry from the Canadian Medical Association (CMA) and other health care organizations, which fear the loss of an independent voice to monitor health system performance and reform. CMA president, Dr. Anna Reid asked: “How are we to transform the health care system to improve patient care if we can’t measure what we’re doing well and what we need to improve?” and argued that “Canada’s health care system needs all the information it can get, but instead we are about to lose one of the few bodies responsible for monitoring and measuring progress toward ensuring the health care system is able to meet the needs of Canadians.” Other health care advocates such as the Council of Canadians and the Canadian Health Coalition worried that dismantling the council will create a gap in knowledge about how well different parts of the country perform on health care. Several provinces expressed concern that the Council contributed to sharing information across jurisdictions.
It may be useful to step back from the immediate controversy to assess its implications for health care reform. Let’s begin from a powerful framework commonly used to analyze and compare the structure and performance of health care systems: identifying the essential features of a high performing health care system, assessing where your system is in relation to these defining elements and analyzing how to improve along the identified lines? Essentially, we are asking what are the success conditions for significant system transformation? Where and how do the functions fulfilled or potentially fulfilled by the HCC contribute?
Three vital success conditions are especially relevant here. The first is about enabling and driving innovation:
- Identifying promising practices;
- Evaluating what is working, for which purposes and populations, in what organizational and social contexts?
- Sharing lessons learned;
- Providing evidence-based and easy to use guidance and support for practitioners and decision makers.
Clearly, forums and institutions are needed to organize and coordinate this knowledge sharing and management. HCC has played an important role in highlighting areas of innovation. But it has been limited in its ability to monitor, enable or drive implementation of promising practices.
The challenge becomes clearer when considering a second success condition for system change and improvement: creating a comprehensive and integrated performance measurement and monitoring system. The Council played a role in identifying measurement structures to some degree and monitoring some key dimensions. Arguably, a more comprehensive and coordinated system is needed. Many provinces have quality councils or other structures performing elements of system monitoring and reporting. There would be great value in these functions being coordinated and consistent. For example, each province using a similar suite of equity indicators would help to identity the trends and contours of health inequities much better. The federal, provincial and territorial governments could recognize the importance of this coordination and given the HCC a role here.
However, the reason for this limited performance monitoring and improvement lies in a third key success condition: tying performance measuring and management to resource allocation, funding incentives, accountability mechanisms and other system drivers. In other words, giving performance measurement teeth and traction. HCC did not have this kind of power; nor does any other current institution. The problem is structural: the provinces and territories are responsible for health care policy and delivery; the federal government provides some significant funding but has steadily pulled back from attaching those funds to performance or outcome requirements; and the result is a fragmented system of 13 health care systems. In effect, there is no national health care system in Canada.
Key policy and system questions then arise. Is there value in national forums and mechanisms to share lessons learned and drive innovation across the country? The answer is absolutely yes. Given that the HCC exists and has a track record in this area, this implies that the Council should be retained and strengthened.
Could comparative performance measurement and monitoring contribute to more consistent and equitable delivery of care across the country? Yes again. A starting point could be for each jurisdiction to commit to comprehensive system measurement and monitoring – some provinces are very advanced. Even better would be Federal-Provincial-Territorial commitment to sharing results and moving towards consistent standards, indicators, data collection and performance measurement systems. A strengthened HCC could be part of that, but the real challenge is political will.
Similarly, would embedding performance measurement and monitoring into broader management, resource allocation, accountability and system drivers be useful? Yes again. And again, at best in a coordinated and collaborative way that enables cross-jurisdictional innovation and sharing. This would need to be a considerably strengthened institution than the current HCC. And it can only come out of more serious strategic commitment from all governments to health care reform that moves well beyond the current fragmented system.