ARCHIVED - Report to the Federal Minister of Health: Towards a New Leadership For The Improvement of Health Services in French - February 2007

Submitted by the Consultative Committee for French-Speaking Minority Communities
February 2007
ISBN (978-0-662-49856-8)
Catalogue No (H21-287/2007)

Table of Contents

Summary

In June 2001, the Consultative Committee for French-Speaking Minority Communities (CCFSMC) submitted its first report to the federal Minister of Health, Pour un meilleur accès à des services de santé en français. In the report, the CCFSMC reviewed access to health services in French and identified levers of intervention for improving access to these services. The report focused on the fact that the quality of health services is closely tied to the ability of health care providers to communicate in the language of their patients and thus assist, advise, direct and educate them. The ability to understand and be understood is an essential component of effective relationships between health care providers and health services users, and is critical when the health and well-being of patients requires changing behaviours, developing new habits or following treatment and drug regimens to the letter.

Need to review the 2001 strategy

Our 2001 report served as a guide for the federal Action Plan for Official Languages launched in March 2003. The Plan actively supported the CCFSMC's proposed directions and provided financial support for certain strategic initiatives. This financial support, covering the period 2003-2008, is focused on a number of levers and actions identified by the CCFSMC in 2001. At its September 2005 meeting, the Committee decided to assess the impact of efforts to date, and validate the strategic directions that had guided its recommendations.

The CCFSMC decided to review its 2001 strategy, even though the implementation of initiatives to support health services in French is recent. This update proved useful in several respects: certain federal initiatives funded under the 2003 Action Plan have ended, a new government has been elected, several provincial strategies focusing on health and a greater awareness of the role and importance of primary health care services have emerged, and health services have evolved overall.

This second report to the federal Minister of Health summarizes the Committee's analysis of recent developments, the current situation and outlooks for the future, and presents our recommendations on the best strategy for continuing to improve access to health services in Francophone minority communities.

Strategic objectives and key initiatives

The goal of the CCFSMC is to promote an environment and conditions for improving the health of Francophones in minority communities. To achieve this goal, the Committee focuses on two major objectives:

  1. increasing the availability of French-speaking health professionals in the communities; and
  2. improving access to health services in French for Francophone minority communities.

The achievement of these two objectives will in turn generate greater satisfaction among Francophone communities and get them more involved in taking responsibility for their health.

stragtegic objectives chart

To achieve these major strategic objectives, in 2001 CCFSMC recommended various measures based on five key levers:

  • networking among health care partners;
  • health care training;
  • organization of health services;
  • research on the health of minority communities;
  • use of health technologies.

The 2003 federal Action Plan adopted this approach in certain respects by funding two major strategic initiatives: the Consortium national de formation en santé (CNFS), the organization mainly responsible for the training and research levers, and the Société Santé en français (SSF), the organization mainly responsible for the networking and services organization levers. Each of these organizations was given its own objectives and financial goals for 2003-2008, and agreed to create two joint consultative committees, one for human resources and the other for research. The mixed nature of these two issues made it possible to achieve the objectives more effectively. These two major federal initiatives spearheaded the deployment of the strategy developed in 2001 by CCFSMC, and the federal government has supported other smaller initiatives and projects in recent years.

Creating the conditions to facilitate the desired changes

First, we must point out that it is still too early to conduct a detailed review of all the initiatives that were launched. Several initiatives did not actually begin until mid-2003 and were not deployed until 2004. Two years is obviously too short a time frame for determining whether there have been significant changes in the health of Francophones in minority communities, particularly given that the goal of the approach was to structurally change access to health services in French, and thus focused on mobilizing the various parties in question, involving the provinces, increasing the number of health professionals, having individuals and communities take responsibility for their health, and so on. All of these are structural changes that take time.

However, the Committee's review shows that several of the facilitating conditions required are in now in place and that the situation today is better than it was in 2001. Midterm, we are seeing greater awareness on the part of Francophone communities, action by health partners, official recognition of several networks by provincial and territorial authorities, the creation of provincial and territorial development plans for addressing the health issues facing Francophone minority communities, a greater number of Francophone graduates in the health professions, and greater availability of health services in French. Moreover, the approach implemented in 2001 is supported by primary care authorities in most provinces and territories and has been recognized by the Network-TUFH (affiliated with the World Health Organization) as an innovative approach that meets community needs.

activities receiving financial assistance

Progress has been made on each lever but major challenges remain

The news midterm is also positive in terms of the levers of intervention. Through their activities, the SSF and its networks have been catalysts, developing promising initiatives for increasing resource visibility and enhancing the active offer of services, while the activities of the CNFS and its members institutions have produced and continue to produce an increase in the number of available professionals by offering initial training and professional development via continuing education, resulting in several significant achievements despite the fact that these measures have only recently been deployed. However, despite these positive developments, major challenges still lie ahead for each intervention lever.

Progress per intervention lever
Lever Key achievements Key challenges
Networking
  • Implementing 17 networks across Canada
  • Awareness of and concerted effort by health partners
  • Development of close relationships with several provincial/territorial governments
  • Support for health services planning in the provinces and territories
  • Prioritizing, organizing and implementing promising initiatives in the area of access to health services
  • Establishing and maintaining productive relationships with all provinces and territories
  • Further mobilizing health care professionals and institutions
  • Availability of qualified people to lead and direct networks
Training
  • Establishing new co-operative relationships among training institutions
  • Exceeding objectives for increasing health profession enrolments and graduates
  • Increasing French-language training capacity
  • Launching new health training programs, including continuing education
  • Need for professionals outstripping training capacity
  • Getting graduates to return to or settle in minority communities
  • Aligning training with priority needs of minority communities
  • Providing enough internships in minority communities
  • Balancing the geographic distribution of students enrolled in programs
Research
  • Creating a joint commission
  • Raising awareness of national research councils and creating an advisory committee within CIHR
  • Developing a reference framework for focusing applied research on community needs
  • Funding five major research projects
  • Placing more priority on research activities
  • Directing research and using research findings
  • Need to establish critical mass required to conduct more extensive and in-depth research
  • Need for strategic measures
Health Services
  • Implementing 71 projects in all provinces and territories
  • Concrete involvement by various stakeholder groups
  • Significant participation by provinces and territories
  • Maintaining the mobilization of authorities responsible for services
  • Prioritizing projects
  • Project synergies/complementarity
  • Developing models adapted to the various communities
Technology
  • No budget was earmarked for this lever
  • Importance of investments associated with this lever
  • Need for close co-operation with the provinces and territories

The comprehensive approach

There is no doubt that access to French-language health services is better in 2006 than it was in 2001, the result of various achievements stemming from 2003 Action Plan initiatives. However, it is also obvious that even greater sustained effort will be required to produce the desired structural changes. By the same token, we must recognize that the current measures had limitations at the outset and still do. For each of the two major objectives, i.e., increasing the availability of Francophone health professionals in the communities and improving access to health services in French, more must be done and in some cases, perhaps done differently.

In updating its strategy, CCFSMC endeavoured to build on recent improvements while identifying the adjustments needed to achieve the target objectives more quickly and more effectively. With this in mind, the Committee defined six sub-objectives for increasing the availability of Francophone professionals in minority communities and improving access to health services in French:

  1. Increase the pool of Francophone health professionals
  2. Promote the placement of graduates in the communities
  3. Attract professionals to the communities and keep them there
  4. Mobilize professionals already in the communities
  5. Educate and involve the community
  6. Develop an active offer of health services

the comprehensive approach

Sub-objectives 1, 5 and 6 were already explicitly acknowledged in the objectives for the initiatives funded since 2003. Sub-objectives 2, 3 and 4 were not as clearly stated and, according to the Committee, deserve attention and specific action. The CCFSMC's second report therefore seeks to improve the overall approach in order to achieve the ultimate goal more quickly and effectively, i.e., improving access to health services in Francophone minority communities.

Foundations of the proposed strategic directions

Progress achieved since the first report shows that improving the quality of health services for Canada's one million French-speaking citizens living in minority communities is fully attainable, despite the challenges and constraints of that objective. The CCFSMC is even more convinced today that the success of its initiative depends on approaches that focus on mobilizing and coordinating resources in order to facilitate the implementation of more effective prevention and health promotion strategies. These approaches require the combined support of the federal government, provincial/territorial governments, the communities themselves, health care professionals, health care establishments and training institutions. In addition to prioritizing the adjustments needed to ensure that more is done, more effectively and more quickly, the Committee believes that we need to reiterate a number of factors that are essential to achieving its mandate, as follows.

  • The measurement of results. The Committee reaffirms the importance of setting and adhering to objectives and intends to play a broader role in determining the objectives of the various federally funded initiatives and establishing a comprehensive assessment framework for its strategy.
  • The essential involvement of the provinces/territories. The Committee reaffirms the importance of continued cooperation with the provinces and territories and ensuring that the proposed solutions, particularly those for improving access to health services in French, are clearly aligned with their directions, choices and priorities.
  • The leveraging role of the federal government. The Committee also believes that the federal government must capitalize further on its leveraging effect and play a leadership role in improving health care in Francophone minority communities.
  • The cooperative approach by health partners. The Committee remains convinced that the viability and effectiveness of health systems depend on real cooperation among all key partners.

Recommendations and priorities

Based on experience in recent years, CCFSMC has reaffirmed certain directions, but also suggested some adjustments. In this respect, we submit the following recommendations to the Minister of Health.

Recommendation 1. Continue efforts made in recent years to improve the health of Francophones in minority communities. Based on experience acquired in the last three years, we have built on several of the conditions essential to achieving the target results. Several concrete measures that will produce the desired improvements are underway. An even partial withdrawal by the federal government could, at this stage, interrupt the current momentum, reduce community involvement and compromise or even result in the termination of some initiatives, while irritating provinces or territories engaged in strategic activities with their Francophone communities.

Recommendation 2. Maintain primary health services as a priority, with seniors and children as priority client groups. These client groups are the most vulnerable and the lack of health services in their languages impacts them the most. In terms of types of care, all stakeholders recognize the importance of primary health care services to improving individual health, and to the quality and effectiveness of the system. Recent reforms in provincial and territorial health care systems have also recognized the critical importance of primary care.

Recommendation 3. Work on the five identified levels (networking, training, access, research and technology) but give priority to the first four. In recent years, efforts have focused mainly on the first three levers, i.e., those that had the greatest immediate impact on key services and target client groups. From a medium-term perspective, we now need to include research as a priority lever. This would allow us to better measure results and better identify the service models that best meet community needs and governments' expectations.

Recommendation 4. Do more, and in some cases, do things differently for each of the two major intermediate objectives (increasing the availability of Francophone health professionals in the communities and improving access to health services in French). Specifically, this means focusing on all available pools of new Francophone professionals. The Committee still believes that the greatest potential lies with Francophone students enrolled in health programs in Francophone institutions, but more effort will be required in coming years to interest Francophone students enrolled in English-language institutions, as well as qualified Francophile immigrants, in settling in Francophone minority communities. Similarly, initiatives for attracting and retaining health professionals must be increased, and by the same token, efforts at encouraging and mobilizing the health care community must be expanded, particularly in terms of service points and professional associations. Also, the types of training that are funded should be better aligned with the priority needs of Francophone minority communities. Finally, the development of a truly active offer of French-language health services is still a priority and, as a result, the resources devoted to implementing new and high-performing models for delivering these services and for disseminating these models must remain equal to the challenges facing us.

Recommendation 5. Help community institutions achieve target objectives effectively. To date, two major strategic initiatives have been supported: the Consortium national de formation en santé (CNFS) and the Société Santé en français (SSF). This dual structure was adopted to reflect the specific characteristics of both training institutions and local communities. The CNFS and SSF very quickly identified common issues and created joint committees for addressing these issues. Based on recent experience, we believe that this dual structure is still appropriate for stimulating the desired level of involvement among the target communities and facilitating achievement of the target objectives. However, it is also obvious to the Committee that joint issues are becoming both more numerous and more important, particularly in the area of human resources. We believe it would be a good idea to explicitly recognize this need for close alignment by establishing a number of objectives that are common to both organizations.

Recommendation 6. Further integrate professional associations within the strategy. Increasing the number of health professionals settling and staying in Francophone minority communities requires establishing close relationships with the individuals offering these services. The CNFS and SSF have been very sensitive to this need in recent years and have built bridges in specific areas. However, the Committee believes that these relationships must become more intense and sustained in order to create all the conditions essential to achieving the desired results. Obviously, this means more effectively integrating the orders and associations that accredit and represent the various health professions, particularly those representing doctors and nurses.

Recommendation 7. Devote the appropriate financial resources to achieving established objectives and ensure that their terms and conditions are straightforward as well as results-based. Federal funding has acted as an important lever in recent years, and is the preferred approach for the next phase of the strategy. However, the budget approval and tracking process for certain programs was particularly cumbersome and adversely affected certain projects. These adverse effects can be mitigated via close cooperation and effective information sharing between the Department and community institutions, while continuing to comply with legislation and regulations governing the administration of public funds.

The challenge of improving the health of Francophones in minority communities can be met successfully only if governments are open, institutions and health professionals are involved and Francophone communities take action. The Committee's approach is designed to develop this momentum for change. It is asking the Francophone minority communities, with its health partners, to take responsibility for and take action to improve access to health services in French in their communities.

To succeed, the Committee is counting on new leadership from all interested parties, leadership that will result in improved health for Francophones in minority communities and in the further development and vitality of these communities.

Introduction

Mandate of the Consultative Committee for French-Speaking Minority Communities (CCFSMC)

In August 1994, the Government of Canada approved the establishment of an accountability framework for the implementation of sections 41 and 42 of the Official Languages Act, which are aimed at ensuring that not only do official-language minority communities have access to services in their language, but that all federal institutions actively contribute to the development and vitality of these communities.

In June 2000, the federal Minister of Health created the Consultative Committee for French-Speaking Minority Communities (CCFSMC) to address health issues facing Francophone communities1. The Committee is co-chaired by Hubert Gauthier, President and CEO of the Société Santé en français and former President and CEO of the St. Boniface General Hospital (Manitoba), and by Marcel Nouvet, Assistant Deputy Minister, Corporate Services Branch and Official Languages Champion at Health Canada.

The Committee's mission is as follows.

  • Advise the federal Minister of Health on ways to enhance the vitality of Francophone minority communities and support their development.
  • Advise the federal Minister of Health, the Public Health Agency of Canada and the Department on the coordination of federal health initiatives.
  • Provide advice on initiatives proposed at the various development and implementation steps to ensure that Francophone minority communities derive maximum benefit from these initiatives.
  • Maintain relationships with Francophone minority communities to facilitate information sharing.
  • Act as a forum to help update the multiyear Action Plan and thus assist the Department in meeting its obligations under section 41 of the Official Languages Act.

The Act was reinforced on November 25, 2005 with the adoption of the Act to Amend the Official Languages Act (promotion of English and French), aimed at ensuring that all federal institutions take positive measures to meet their obligations and making Part VII of the Act enforceable.

The CCFSMC is made up of:

  • two co-chairs, one representing the community and one representing the Government of Canada;
  • seven members representing French-speaking minority communities;
  • three representatives of provincial governments (Manitoba, Alberta and New Brunswick) and one representative of Intergovernmental Francophone Affairs;
  • senior Health Canada officials responsible for priority areas;
  • the National Coordinator, Official Languages Act, Part VII and other departmental and regional coordinators, as required;
  • two representatives of Canadian Heritage (Official Languages Secretariat and Interdepartmental Coordination);
  • One representative of the Public Health Agency of Canada; and
  • Two secretaries, one for the community side and one for the federal side.

The Committee's 2001 report and subsequent work

In June 2001, the Committee released an initial study funded by Health Canada and coordinated by the Fédération des communautés francophones et acadiennes du Canada (FCFA). The report, entitled Pour un meilleur accès à des services de santé en français, provided an overview of access to health services in French and identified levers liable to enhance access to these services. The Committee then created working groups, each mandated to do an in-depth study of one or more of the levers liable to improve access to French health services. Their findings were submitted in a report to the federal Minister of Health in September 2001.

This report served as a guide for the federal Action Plan for Official Languages launched in March 2003. The Plan actively supported the CCFSMC's proposed directions and provided financial support for certain strategic initiatives to support improvements in health services for minority Francophone communities. This financial support, covering the period 2003-2008, is focused on a number of levers and actions identified by the CCFSMC. At the same time, this exercise created momentum in increasing awareness of the importance of offering health services in the patient's language, among all the parties concerned: health professionals, provincial and territorial governments, institutional service providers and community groups.

After submitting its report to the Minister, the CCFSMC continued its work and held several meetings to ensure implementation of the strategy. At its September 2005 meeting, the Committee decided to assess the impact of efforts to date and validate the strategic directions that had guided its recommendations.

Updating the 2001 strategy

The CCFSMC decided to review its 2001 strategy, even though the implementation of initiatives to support French-language health services in Francophone minority communities is recent. This update proved useful in several respects: certain federal initiatives funded under the 2003 Action Plan have ended, a new government has been elected, several provincial strategies focusing on health and a greater awareness of the role and importance of primary health care services have emerged, and health services have evolved overall.

Obviously, the review process drew on Committee members' experience and their direct involvement in the issue of health in Francophone minority communities. Various evaluation reports prepared in recent months and covering various aspects of the initiatives funded under the federal Plan also provided input, specifically:

  • The update on initiatives proposed by the CCFSMC, released in October 2005 (Health Canada, Moving Forward in the Health Sector);
  • The Midterm Report on the Action Plan on Official Languages filed in 2005 (Government of Canada, Update on the Implementation of the Action Plan for Official Languages);
  • The mid-term evaluation report on CNFS activities, finalized in early 2006 (CNFS Report on the Formative Evaluation report of the Health Care Training and Research Project);
  • The preliminary midterm evaluation report on SSF activities, available in the summer of 2006;
  • The evaluation report on the PHCTF project with the Association of Canadian Medical Colleges filed in July 2006 (Physicians and Care of Quality for Canadian Francophone Minority Communities).

The Committee also hired a consulting firm to conduct research to complete its analysis of the current situation,2 including a review of the relevant literature. The status of health services also underwent a quantitative update to assess progress made since 2001. Finally, members of training institutions, governments and Francophone minority communities were interviewed. These meetings included:

  • provincial and territorial officials responsible for services to Francophone communities;
  • provincial and territorial officials responsible for primary care;
  • federal officials responsible for primary care and new health technologies;
  • each of the 17 networks formed under the 2003 Action Plan in each province and territory;
  • each of the 10 training establishments that are members of the Consortium national de formation en santé (CNFS); and
  • officials from various bodies involved in health issues.

The Committee met in June 2006 to discuss a preliminary update and various issues relating to each of the levers recommended in its 2001 report. In September 2006, the Committee met again to validate the 2001-2005 assessment, finalize directions and priorities for the post-2008 period and determine what adjustments are required in the deployment of the preferred strategy.

This document summarizes the Committee's analysis of recent developments, the current situation and outlooks for the future. We start by reiterating the importance of French-language health services and the key observations of the 2001 report. We then provide a brief overview of developments and achievements since the federal plan was submitted, and then conclude by describing the Committee's recommendations, which are aimed at ensuring new leadership in improving access to health services in Francophone minority communities.

Background

The importance of health services in French

The importance of access to French-language health services for members of Francophone minority communities cannot be overemphasized. Our 2001 report, Pour un meilleur accès à des services de santé en français, focused on the fact that quality health care services are not limited to patient care techniques. Quality is also closely tied to the ability of health care providers to assist, advise, direct and educate service users. The ability to understand and be understood is thus an essential component of effective relationships between health care providers and health services users, and becomes particularly critical when the health and well-being of patients requires changing behaviours, developing new habits or following treatment and drug regimens to the letter.

Access to health services in one's own language is much more than showing respect for the culture of the person using the services. It is sometimes essential to improving health and ensuring that the population takes responsibility for their own health. Several 2001 studies 3 confirm the importance of language to the effectiveness of certain types of care and conclude that the language barrier:

  • reduces recourse to preventive services;
  • increases consultation time, the number of diagnostic tests and the probability of diagnostic and treatment errors;
  • affects the quality of services where effective communication is essential (e.g., social services, physiotherapy, occupational therapy, and mental health);
  • reduces the probability of treatment compliance; and
  • reduces the service users' satisfaction with the care and services they receive. 4

This means that access to French-language health services not only improves the quality of services received by Francophones in minority communities and consequently leads to greater user satisfaction, it may ultimately be a way to improve the effectiveness of health care services through:

  • better disease prevention: less need for health care services and shorter waiting times;
  • more accurate and faster diagnoses: more efficient primary, secondary and tertiary care; and
  • better communication and greater medication compliance: the services provided have greater impact.

Review of the situation in 2001

Poorer health

In 2001, when the CCFSMC's first report to the federal Minister of Health was being prepared, the comparative analysis of the socio-economic characteristics of 71 Francophone minority communities showed that Francophone and Acadian minority communities were more likely to have health problems than Anglophone majority communities, owing to their isolation and the fact that their residents are older, less educated and less active in the labour market, and so on. These findings were confirmed in several other related studies.

Less access

The 2001 analysis of the 71 minority Francophone communities also revealed that between 50% and 55% of Francophones in minority communities had never or almost never accessed French-language health-care services, whether in a private clinic, hospital, community health centre or other facility. Significant discrepancies between French- and English-language services in these communities were also identified: health care services were three to seven times more accessible in English.

Major differences among communities

The Committee's work also led to two important findings.

  • Major regional differences. Although some of the observed differences in access to services could be explained by the number of Francophones and their population density, the Committee also noted significant differences among "comparable" regions. 5 In other words, demographically similar communities could present major differences in terms of access to services, meaning that important non-demographic factors were affecting accessibility.
  • Potential improvements across the board. Although Francophones in certain regions had better access to French-language health services, more could still be done. No region could say it had done all it could.

The 2001 intervention strategy

This was the situation in 2001 when the CCFSMC decided that it was essential to educate the various stakeholders involved in health services in minority communities, and to develop a strategy for improving access to services in French. This strategy comprised several components focusing equally on basic principles, fundamental directions and preferred means for taking action.

The five levers

The CCFSMC thus decided to take an approach based on primary health care services and aimed at strengthening individual accountability and community capacity building in the prevention and treatment of health problems. The Committee proposed working on the following five levers to help effect the desired changes.

  • Networking: to promote community action and involvement, identify and prioritize needs, facilitate access to Francophone professionals and implement promising initiatives.
  • Training: to ensure the availability of Francophone health care professionals in the short, medium and long terms.
  • Access to services: to group Francophone health care professionals together and direct Francophones to Francophone resources or service points where French is spoken and there is a physical, visible and concrete active offer of French-language services.
  • Technology: to strengthen the patient-professional relationship via telemedicine and call centres and thus facilitate consultations among professionals and make maximum use of electronic data on patient health.
  • Research: to better understand the health problems of Francophones in minority communities and help stakeholders set priorities for French-language health services.

Strategic premises

Through its analyses of Francophone minority communities and a review of the existing situation and initiatives, the Committee identified four guiding principles for making the recommended strategy more effective.

  • The need to address both supply and demand. On the one hand, institutions and government departments responsible for delivering health care services require constant support for their "Francization" efforts and strong encouragement to overcome the obstacles they encounter. A proactive offer of service is therefore essential to improving access to services in French. On the other hand, Francophone communities and individuals must also be encouraged to express their needs clearly in their language and to make use of French-language services.
  • The need for a concerted effort. Improved access to French-language health services is even more attainable if it is based on concerted efforts by all major stakeholder groups: health care professionals, health managers (including health care establishments), political decision-makers, training institutions and the communities involved. Significant and sustained involvement by each of these stakeholders is required to reduce the many obstacles to improving access and creating facilitating conditions, i.e.,

    • community involvement: community recognition of the importance of French-language health services so that communities will identify needs and create demand;
    • facilitating institutional structures: the implementation of more official planning, coordination and delivery mechanisms, as part of existing health networks, via structures or mechanisms that encourage Francophone minority communities to take greater responsibility for health; and
    • political will: government involvement via policy, legislation or regulations that recognize the importance of access to French-language health services for Francophone minority communities.
  • The recognition of regional differences. Current and potential access to French-language health services varies significantly from region to region, and the proposed approaches must take into account the characteristics of each target community. An "across the board" or overly-standardized approach is not at all appropriate.
  • The importance of community participation. Experience shows that the more Francophones are involved in the care delivery process, including managing health care institutions, the more French is respected and reflected in service delivery. This participation is also crucial if the population is to take real responsibility for health.

Strategic objectives

The CCFSMC report aimed at promoting an environment and conditions for improving the health of Francophones in minority communities. To achieve this goal, the Committee focused on two major objectives: i) increasing the availability of French-speaking health professionals in the communities, and ii) improving access to health services in French for Francophone minority communities. The achievement of these two objectives will in turn generate greater satisfaction and participation among Francophone communities and ultimately an improvement in the situation of Francophone communities.

strategic objectives

Activities funded under the federal plan

To achieve these two major strategic objectives, the CCFSMC proposed various measures or initiatives. The 2003 federal Action Plan essentially endorsed this approach by funding two major strategic initiatives: the Consortium national de formation en santé (CNFS) and the Société Santé en français (SSF). Each of these organizations established its own objectives and financial goals for 2003-2008, and they were both responsible for spearheading the deployment of the strategy developed in 2001 by CCFSMC.

Two governing bodies and five elements of the strategy
Elements of the strategy* Training (prioritized) Research (not prioritized) Networking (prioritized) Organization of services (prioritized) Technology (not prioritized)
Governing bodies
Consortium national de formation en santé Leadership of the lever Shared management via the joint research committee
Société Santé en français Contribution via the joint HR committee Shared management via the joint research committee Leadership of the lever Leadership of the lever Limited contribution via budgets earmarked for service points
*
Including the aspect prioritized or not prioritized by the federal Action Plan

The activities of the Consortium national de formation en santé (CNFS) focus on two of the Committee's five levers, i.e., training and research. The CNFS comprises ten universities and colleges across Canada offering programs in French in the various health disciplines, as well as a national secretariat. In 2003, Health Canada gave the CNFS a $63 million budget to invest in the training lever and to a lesser extent, in the research lever. This funding covers the period 2003 to 2008.

The Société Santé en français supports the implementation of the three other strategic levers, i.e., networking, the organization of health services and technology, although the latter does not receive specific funding. The networking lever is different in that it serves as a catalyst and supports the implementation of the other levers. An annual budget of $2 million for 2003-2008 was granted to create the networks and support their activities to get stakeholders to mobilize and take action together. 6 Also, as of 2004, the SSF has also been responsible for coordinating a special budget of $20 million under the Primary Health Care Transition Fund (PHCTF). This budget was earmarked for projects to improve access to French-language health care services.

Also, the two organizations agreed to set up two joint consultative committees, one for human resources and the other for research. The mixed nature of these two issues made it possible to achieve the objectives more effectively.

The federal government has also supported other initiatives and projects, for example, the Association of Faculties of Medicine of Canada (AFMC) project, titled Health Care Needs of the Francophone Communities Outside Quebec and funded by AFMC, which identified Francophone doctors and students in most faculties of medicine, created internships in Francophone communities and initiated networking. On May 2, 2006, the AFMC's Resource Group, Francophone Minority Communities in Canada (RG/FMC) was created and mandated to support the development of a medical labour force for Canada's Francophone minority communities and thus enhance the supply of medical services and the health of the population of these communities. Also, Infoway initiatives have had positive repercussions for Francophones.

The general context for health care in Canada, the awareness of the need to support official language minority communities and the work of the Official Language Community Development Bureau of Health Canada have also made a difference. These other positive elements include:

  • the recommendations of the Romanow and Kirby reports in 2003, which support the Committee's proposed directions;
  • the changes to provincial and territorial health care systems since 2001, several of which explicitly recognize the specific health needs of minority communities (e.g., New Brunswick and Ontario);
  • the recent reforms to provincial and territorial health care systems recognizing the importance of primary health care to effective and high-quality services, which is the core of the Committee's 2001 recommended approach;
  • the amendments to the Official Languages Act (Bill S-3) to strengthen support for public services in both languages;
  • the direct and indirect support of the Quebec government for the Committee's priority activities (e.g., lending of personnel, support for the Quebec/New Brunswick agreement);
  • increased support for bilingualism across Canada and in each of the provinces (for example, see the 2006 survey by the Office of the Commissioner of Official Languages 7), which fosters openness to the initiatives that have been developed.

Brief overview of the 2001 strategy

Although the CCFSMC submitted its report to the Minister of Health in September 2001 and the federal Plan was launched in March 2003, several initiatives did not actually begin until mid-2003 and were not deployed until 2004. Two years is obviously too short a time frame for determining whether there have been significant changes in the health of Francophones in minority communities, particularly given that the goal of the approach was to structurally change access to health services in French. The focus was on mobilizing the various players, getting the provinces involved, increasing the number of health professionals, having individuals and communities take responsibility for their health, and so on. All of these are structural changes that take time. However, the brief review shows that several of the facilitating conditions are in place today and that the situation today is better than it was in 2001. This 2006 portrait will also give us an idea of the limitations of the initiatives launched to date.

Activities funded under the federal plan

Networking achievements to date

The goal of networking is to create concrete and lasting links among stakeholders interested in securing better access to health services in French. In this respect, the SSF first contributed to implementing 17 networks that bring together, in each province and territory with Francophone minority communities, representatives of each of the five main partners involved in improving access to French-language health services, i.e., the health professions, managers of health institutions, political decision-makers, academic institutions and the communities. Each network has adopted a governance model that reflects this representation and has established specific objectives.

Educating and bringing these partners together in order to get their concrete support and commitment has been one of the networks' key activities, and probably their greatest success to date. Many of the activities have had the result of mobilizing the various stakeholders, for example, meetings every four to 12 weeks of committees composed of representatives of the five stakeholder groups, training workshops for health care professionals (in eight networks), the organization of approximately 75 conferences, and the launch of more than 71 initiatives relating to access to health services (see the next section), one-third of them led by regional authorities, one-third by health agencies (hospitals, community centres) and one-third by the community (often via the network itself).

In all the networks, community involvement has translated into loans of resources, for example, loans of staff (five networks) or services (three networks). In all, the networks have received support from over 125 stakeholders from each group of partners, and at least one representative of each partner attends the general meetings (250 individuals in total).

Through their actions, the networks have contributed not only to getting the community involved, but to the emergence of facilitating institutional structures and a political will, conditions identified by the Committee as key factors in improving French-language health services. In several cases, the networks have developed close relationships with the provincial authorities (see the table below).

Network-Province relationships are generally good or very good
Province Status of relationship, according to the province Role or network recognized by the province Participation of the province in the network
Newfoundland/Labrador A challenge None No
Nova Scotia Very good Official role upcoming Yes
New Brunswick Very good Official role Yes
Prince Edward Island Good to very good Official role Yes
Ontario Good to very good Official role Yes
Manitoba Very good Official role Yes
Saskatchewan A challenge None No
Alberta Good Consulting role No
British Columbia Very good Consulting role Yes
Northwest Territories A challenge None No
Yukon Good None Yes

The provinces report having good to very good relationships with almost all the networks. Six networks (New Brunswick (3), Prince Edward Island, Ontario and Manitoba) have been assigned the role of official representative of Francophone communities on health matters (see box: Recognition of the network's official role in Manitoba) and another network could be given that role soon (Nova Scotia).

Via the networks, communities are able to take action on key health-related issues and, among other issues, better plan the development of French-language health services across the country, based on the needs, means and priorities of each region. In 2005, a service planning project, Setting the Stage, proposed by the SSF and supported by Health Canada, was initiated by the networks to support the efforts of provincial and territorial departments of health and regional health authorities interested in improving access to French-language health services for their Francophone populations. All the provincial and territorial departments confirmed their support for the Setting the Stage project.

Recognition Of The Network's Official Role In Manitoba

Manitoba's Department of Health and Department of Family Services and Housing designated the network (Conseil communauté en santé or CCS) official representative of the Francophone community for health and social services. In addition to representatives of other health partners, the network's by-laws provide for government representation, including representatives of regional health offices and a senior official from the Department of Health, the Department of Family Services and the French Language Services Secretariat.

It was also agreed that, to ensure linkages between the Francophone community and the Regional Health Offices, the Department of Health would appoint a number of directors to the Boards of Directors of RHOs that are designated bilingual, from a list provided by the Société franco-manitobaine, which is the provincial representative of the Francophone community.

CCS activities fall under five categories: support for planning French-language services, support for developing and implementing French-language service plans, communication and networking, HR training, recruitment and retention, and support services (translation, language training, documentary resources, and so on).

These primary health plans, prepared for each province and territory with the cooperation of the community, include the following elements: an update on the health situation of the various Francophone minority communities, needs identification, primary health care priorities with a view to the situation of each Francophone minority community (by province and territory) and the best strategies for achieving the identified priorities (by province and territory). In most provinces and territories, these kinds of French-language health service updates or priorities did not exist until the networks took action. These plans should be used to provide an overview of the needs of Francophone minority communities and of the health care delivery models adapted to their needs. This planning effort has received positive feedback in all provinces and territories.

Finally, as part of their activities, the networks facilitated the prioritizing, organization and implementation of a large number of promising initiatives (71 funded to date and 18 upcoming) in the area of access to health services.

Key networking challenges

Although networking as envisaged by the CCFSMC in 2001 is an original initiative that has had positive results to date, it is important to identify the key remaining challenges from an improvement or adjustment perspective.

  • Establishing productive relationships with all the provinces and territories: In most provinces and territories, the networks have developed constructive relationships with health authorities, a crucial step given the role and involvement of the provinces and territories in health. Maintaining these relationships in the provinces and territories where they are strong is important, as is striving for effective cooperation in the other provinces and territories.
  • Mobilizing health care professionals and institutions. The networks have devoted a good part of their efforts in recent years to identifying needs, establishing priorities and implementing initiatives supported by the PHCTF. To ensure ongoing improvements to health services in French, it will be important in the coming years to encourage health care professionals and institutions in each community to propose a proactive offer of services in French. By the same token, the scope and types of networks will have to be expanded, locally, regionally or nationally (for example, with the professional associations).
  • Availability of qualified people. The success of the networking role is closely tied to the profile and competencies of the people responsible for the networks. The availability of qualified people to take responsibility for and lead the networks has become a major challenge, given the competencies required (ideally a high degree of soft skills in the area of leadership and significant hard skills in the area of health), the existing pools of personnel in the communities and the uncertainty of the positions offered (limited funding, limited and uncertain tenure).

Training achievements to date

In the area of training, according to the midterm evaluation, the CNFS project is exceeding expected results, for each of the three selected performance indicators. 8 Since 2003, the CNFS has generated:

  • 1,428 additional registrations, for a success rate 33% higher than forecast;
  • 296 additional graduates, for a success rate 32% higher than midterm forecasts; and
  • 4,045 additional training days or 110,207 student days of training.

Note: the significant difference between registrations and graduates is the result of students who had not yet finished their training programs at the time of the March 2006 evaluation.

Additional Registrations Exceeding Forecast Results
Institution Anticipated Registrations Actual Registrations Level of achievement in results
Collège Boréal 191 235 123%
New Brunswick Community College -Campbellton 152 136 89%
Collège universitaire de Saint-Boniface 90 95 106%
La Cité collégiale 265 410 155%
Quebec/New Brunswick agreement 29 21 72%
Campus Saint-Jean 32 26 81%
Laurentian University 89 109 122%
Université de Moncton 125 249 199%
University of Ottawa 87 131 151%
Université Sainte-Anne 13 16 123%
TOTAL CNFS 1,073 1,428 133%

If we look at the total distribution of registrations based on training type, we can see first of all that students registered in CNFS institutions in 58 areas of training, i.e., 28 collegial and 30 university programs. Furthermore, the initiative's greatest impact is in nursing (close to 33% of total registrations). The next four highest programs: social services, paramedic, dental hygiene and occupational therapy/physiotherapy account for 50% of total registrations. It should be noted that the types of training are appropriately aligned with the target objectives, given that most are closely related to the provision of primary care, and the fact that in all of these professions, communication with the patient is a key element in the service provided.

distributions of total registrations

distributions of total registrations

While we cannot identify the geographic origins of the students accounting for the additional registrations in CNFS-member institutions, we can look at the geographic origins of all students enrolled in the target programs (historical enrolments and additional enrolments). Not surprisingly, a large percentage of students come from Ontario and New Brunswick (close to 78% of total registrations), i.e., regions that have the highest concentrations of Francophones in minority situations, and where the main existing institutions are located (see diagram on next page). However, this concentration is higher than the weight of their Francophone communities relative to all Francophone minority communities in Canada. In fact, there are three major levels of "penetration" in health training programs in CNFS-member institutions in the provinces:

  • Ontario and New Brunswick (4.5 to 5.0 registrations per thousand Francophones)
  • Manitoba, Prince Edward Island, Yukon and Northwest Territories (1.5 to 2.5 registrations per thousand Francophones)
  • Other provinces (fewer than 1.0 registrations per thousand Francophones).

Although the initiatives of recent years have produced a significant increase in the number of students entering careers in health care, there are still major discrepancies among students' region of origin.

geographic origins of students

As well as generating higher student numbers and additional programs, CNFS activities have increased French-language health education capacity (addition of 65 instructors and 70 other positions), led to the development of an internship infrastructure (198 additional internships) and increased the geographic reach of the institutions (83 courses publicized). Moreover, some member institutions have helped raise awareness of health careers among young Francophones by adopting a proactive approach to promotion and recruitment, including campaigns targeting those factors that impact career choice. Also, the higher number of interns in the field has helped raise the visibility of French-language services in the communities, while reinforcing the active offer of services in institutions that deliver health care services.

The launch of new programs by the CNFS also exceeded original forecasts. Ten institutions initially agreed to develop and introduce 20 post-secondary programs, but they now anticipate reaching 28 programs, an increase of 40% over their original contractual commitments. To date, they have developed and launched 16 new programs, including the following:

  • New Brunswick Community College/Campbellton campus - medical electrophysiology technician, health care assistant (distance), palliative care (distance), respiratory therapy technician
  • Campus Saint-Jean - bachelor's degree in nursing sciences
  • Université Sainte-Anne - advanced paramedical training (collegial)
  • Collège Boréal - gerontology, physiotherapy / occupational therapy assistant
  • La Cité collégiale - program for nurses trained outside Canada, office clerk, pre-med sciences, integration support services, autism and behavioural sciences, palliative care
  • Université de Moncton - Master's degree in nursing - nurse practitioner, bachelor's degree transfer program in respiratory therapy

We should also point out the partnerships resulting from CNFS activities. Several new programs are the result of new partnerships between establishments, regardless of educational level (i.e., college - university). These joint programs have made it possible to fill gaps in the highest-demand sectors more quickly (see following table).

Member Institution Partnerships
Institution Post-Secondary Program
La Cité collégiale - New Brunswick Community College - Campbellton Campus Palliative care
La Cité collégiale - University of Ottawa Radiation Oncology - in September 2007
Laurentian University - Collège Boréal Bachelor's degree, Nursing
University of Ottawa - Collège universitaire de Saint-Boniface Bachelor's degree / diploma, Nursing
Laurentian University - Université Sainte-Anne Bachelor's degree, Social Work - in September 2006
Université Sainte-Anne - La Cité collégiale Sharing advanced paramedic program content and partnership for putting courses on-line
La Cité Collégiale - Collège Boréal - Sharing instructional material Post-graduate gerontology, palliative care, advanced dental care
Université de Moncton - New Brunswick Community College - Campbellton Campus Respiratory Therapy (applied bachelor's degree; medical laboratory science (applied bachelor's degree); radiology (applied bachelor's degree)

Finally, we would like to note the introduction of existing programs in new regions, thus expanding the geographic availability of French-language training and often allowing health care professionals to take all or part of their training while remaining in or near their home community. This means that they can maintain ties with their community of origin, which fosters the organization of training based on the needs of the region, and subsequently increases the chances of employment in the graduate's home community. There are four such initiatives in place:

  • The Quebec/New Brunswick agreement to create the Centre de formation médicale du Nouveau-Brunswick, and its reach within Atlantic Canada and even across Canada; 9
  • Collège Boréal's introduction of health training programs in five new regions in north and south Ontario (see text box: Expanding Collège Boréal's reach);
  • New Brunswick Community College - Campbellton Campus, with the introduction of a program on the Acadian Peninsula, and
  • Cité collégiale, for its pedagogical, administrative and financial support for the creation of a British Columbia program in cooperation with Éducacentre.

Expanding Collège Boréal's reach

In recent years, Collège Boréal has expanded its health training programs to various regions in Ontario. The Collège has introduced programs in the following communities:

2003-2004

The personal support worker program in Kapuskasing

2004-2005

The personal support worker program in Timmins and Hamiltonin central south-western Ontario.

2005-2006

1) The social service program at the Timminscampus;

2) The pre-med sciences program at all northern campuses (five communities)

  • Hearst
  • Kapuskasing
  • Timmins
  • New Liskeard
  • Nipissing

2006-2007

1) The practical nursing program in the following communities:

  • Hearst,
  • Kapuskasing
  • Timmins
  • New Liskeard

2) Second social service program at the Timmins campus.

Key training challenges

Although training results have so far exceeded forecasts, more must be done to ensure that new health professionals settle in the communities to meet the specific needs of those communities. From an improvement or adjustment perspective, the remaining key challenges are:

  • Getting graduates to return to or settle in the communities. Beyond looking at the number of new graduates from health programs, we need to do everything possible to ensure that these new graduates practise in Francophone minority communities. We must also try to respond as effectively as possible to the needs of communities in all regions of Canada, by paying specific attention to the significant disparities among students' home regions.
  • Aligning training with the priority needs of the communities. Until very recently, there was little information on the specific needs of the various communities. With the Setting the Stage project and more robust data on the health status of Francophones in minority communities, we will be able to better identify overall needs according to the various types of health professionals, and the distribution of those needs by region. It is important to capitalize on this information to better align training with the priority needs of the communities.
  • The availability of internships in the communities. The opportunity for internships in a Francophone minority community, or even in the student's home region, increases the probability that students will settle in or return to the community. This means continuing to devote considerable effort to increasing the number of internships and their geographic distribution, and to developing and supporting internship coordinators.
  • Balancing the geographic distribution of students. The initiatives of the past few years have brought about a significant increase in the number of Francophone students entering the health care professions. However, there are still major discrepancies among students' regions of origin. Additional effort is required to correct these discrepancies.

These challenges require not only the cooperation of CNFS member institutions, they require a commitment from various other stakeholders (networks, professionals, health care institutions, etc.).

Research achievements

The Joint Commission on Health Care Research for Francophones in Minority Situations was created through a CNFS - SSF partnership. Its mandate is to create a framework conducive to the development of health care research, and to promote access to existing data and funding from various sources. A partnership with the Canadian Institute for Research on Linguistic Minorities is providing expertise in research on Francophone minority communities and under an agreement with the CNFS, a full-time resource has been assigned to national coordination.

Since its creation in 2002, the Commission has devoted its energies to gaining a better understanding of the problems researching the health of Francophones in minority communities, to developing a conceptual guiding framework and to identifying key research needs. Three priority research themes were identified: 1) health determinants; 2) governance, management and delivery of French-language health services; and 3) links between language, culture and health. Moreover, an extensive research awareness campaign was initiated to mobilize national research funding organizations, in particular the Canadian Institutes of Health Research (CIHR).

Concrete achievements in this area include:

  • The organization of three regional forums and the first national forum on French-language health research titled La recherche, un levier pouraméliorer la santé held in Ottawa in November 2004, which led to the identification of three national themes for health research on Francophone minority communities and the start of networking among researchers interested in these areas of research.
  • The development of a reference framework to direct research and ensure that it is applied and aligned with the needs of Francophone minority communities.
  • Various networking and support activities for the development of research projects, leading to the submission of 11 requests for funding for research projects and initiatives to national research funding agencies (CIHR and SSHRC). Five projects received funding (see text box, Research Projects Funded by External Agencies).
  • The development and implementation of an awareness-building strategy targeting national research councils. The CIHR Consultative Committee for Official Languages Minority Communities was created, leading to the launch of an initial strategic research funding initiative (priority call with funds earmarked for this area of research) and the creation of a strategic research plan for 2006-2009.
  • Several local research initiatives (project start-ups, survey of the literature, attendance at colloquia, etc.) were funded by CNFS member-institutions ($500 to $2,000), providing support for dozens of students (72 students received scholarships of $500 to $1,000) and small research projects.
  • A survey of the literature (thematic bibliography on the CNFS Web site) and some research papers on the status of health care in linguistic minority communities were published (e.g., the December 2005 report on the health of Francophone minority communities in Ontario 10), validating the relevance of the directions taken.

Research Projects Funded by External Agencies

Of 11 proposals, five received funding for activities under the national research component of the CNFS national secretariat (2004 - 2006).

2004 - CIHR(Canadian Institutes of Health Research)

  • Les déterminants de la santé des minorités francophones: une analyse secondaire de l'Enquête sur la santé dans les collectivités canadiennes, BOUCHARD, Louise, GILBERT, Anne et al., $60,680 (2004-2005).
  • Support for organization of the first National Forum on Research relating to the Health of French-Speaking Minority Communities, and the study titled L'état de la recherche sur la santé des communautés francophones en situation minoritaire, funding obtained by the CNFS, $30,000 (2004).

2006 - CIHR(Canadian Institutes of Health Research)

  • Study of the Social, Environmental, Cultural, and Structural Factors Influencing Health Disparities Among Francophone Populations Living in Minority Context: Creating a National Network. Leis A., Bouchard L. et al. Letter of intent $5,000 (2005) and $748,929 (2006-2011).
  • Mortalité dans les communautés de Langue officielle en situation minoritaire, 1991-2001, Louise Bouchard, Jean-Marie Berthelot and Marie-Hélène Chomienne, $100,528 (2006-2008).

2006 - SSHRC(Social Sciences and Humanities Research Council)

  • Le fait minoritaire et les interventions dans le champ de la santé: capital social et rapport à la majorité, Louise Bouchard, Maurice Lévesque and Anne Gilbert, $117,702 (2006-2009).

Although we can be proud of the progress that has been made, research activities are still tentative and we are just starting to learn more about health in Francophone minority communities. Links between academic institutions, practitioners and community partners are a major factor in ensuring the relevance and production of useful evidence for decision-makers and planners. It is also crucial that the funding agencies, with other partners (Canadian Heritage, Health Canada), provide sustainable funding for an issue as important as official languages in the Canadian context so as to ensure the continuing production of information on the health status of Francophone minority communities via more wide-ranging studies that are representative of Francophones in most provinces, by a coordinated network of researchers.

Key research challenges

While research is not one of the levers prioritized in the 2003 Plan, some progress has been made, particularly with respect to concerted action by and awareness of key stakeholders. It is clear that research can and must support the Committee's strategic objectives. The following key challenges must be addressed if this role is to be taken on wholeheartedly:

  • The direction of the research. The themes selected by the Joint Commission are promising because they are aimed specifically at better understanding how the health of Francophones in minority communities can be improved, and at identifying effective delivery models for achieving these results. We must ensure that sustained research continues to focus on the selected themes, that the practical and operational aspects are closely aligned with the analytical method, and that all stakeholders involved are quickly apprised of the results and lessons learned. In short, we have to align this research as closely as possible with the needs of the community, and ensure that the results obtained are used to assist in decision-making and planning by the people responsible in the communities.
  • Critical mass. The resources available for research will probably never be sufficient to establish a viable research capacity across the country. To avoid spreading efforts too thin, we must adopt a critical mass approach and focus energies on a smaller number of strong research clusters. These clusters could bring together researchers from various geographic regions, but they must be created around common strategic projects.
  • Implementation of strategic measures. Beyond achieving the requisite critical mass, we have to ensure that other strategic measures are in place to facilitate major research projects that are consistent with community needs. Specifically, this requires promoting a certain degree of continuity and cohesion in the teams and work being supported to avoid an overly ad hoc approach.

Achievements in improving access to health services

The goal of the access to health services lever is to improve or develop health care services adapted to the needs of regions and communities, within provincial/territorial health systems. It is through the networks, which organized over 71 PHCTF projects in partnership with the community that the SSF has had a real impact on the visibility of and access to health services, an impact we are only starting to feel. Over half of these projects will not be completed until September 2006, and it has taken some committees longer to get organized and submit projects under the first wave of PHCTF projects.

The projects are distributed geographically as follows.

geographic distributions

Access to health service projects structured by the networks fall into several categories, as follows.

Directory of Health Care Professionals in Nova Scotia

In Nova Scotia, a $155,000 investment from Health Canada under the PHCTF was used to create a directory of primary care services offered in French; the directory is available on the government's Web site. This data will be used to provide more information to the Francophone community and improve access to French-language services. An advertising campaign is being used to promote the directory to the public and raise awareness of health services available in their language.

  • Better organization of information on existing resources in order to enhance the visibility of the services offered and increase the ability to respond to demand - approximately 17 initiatives (see text box Directory of health care professionals in Nova Scotia and Development of the Health Guide for British Columbia and the Yukon).
  • Prevention and health promotion in the community, including several initiatives targeting youth (four initiatives) and senior citizens (five initiatives) - approximately 17 initiatives.
  • Better coordination of French-language health care services in a given region so as to improve access and enhance the planning and development of the services - approximately 18 initiatives.
  • Remote access to information and prevention services and specialist care (oncology, cardiology and mental health) via traditional or leading-edge technologies (call centres, Internet, videoconferencing, telemedicine) - approximately six initiatives.
  • Support for health care professionals via networking or the development of French-language support materials - only one initiative is addressing this as a priority, however, several others listed above include a component directly tied to support for professionals.
  • The creation of new French-language primary and some specialist health service points in existing or new health establishments (community centre or hospital) and even in schools (prevention, screening and assessment services) - approximately nine initiatives (see text box Wellness Centre in Notre-Dame-de-Lourdes, Manitoba).

Health Guide for British Columbia and the Yukon

The Health Guide project is a cooperative effort by the provincial Ministry of Health, the Francophone Affairs office and the British Columbia network to produce, distribute and promote the French version of a 400-page guide designed to respond to essential needs for information on health services in French and thus encourage Francophones in British Columbia and the Yukon to take responsibility for their health.

To date, 12,000 copies of the Guide have been distributed and the government has committed to distributing the remaining 12,000 copies. Workshops were organized in all regions of the province to explain how to use the guide, the nursing hot-line and health records, and promotional events in the community were also organized.

In British Columbia, the cooperative relationship between the provincial Ministry of Health and the network is a model that will be repeated with the Chinese and Indo-Canadian communities to develop guides in Chinese and Punjabi.

Wellness Centre in Notre-Dame-de-Lourdes, Manitoba

In Notre-Dame-de-Lourdes, a small community of 619 residents in southwest Manitoba, people have to drive over an hour to access certain health services, which are offered in English only, according to Dr. Fortier, a physician in Notre-Dame-de-Lourdes, discouraging many from using those services, given that over 80% of the local population is Francophone or bilingual and many have trouble expressing themselves in English, thus choosing not to seek treatment if the service is not offered in French.

In response, the community initiated a project, the new Centre de Santé, at a total estimated cost of $2.9 million. The Centre will provide bilingual health services locally for residents of Notre-Dame-de-Lourdes and the surrounding area. In addition to serving people in their community, in French, the Centre also wants to train more bilingual staff on site. Their approach is to focus on primary health care in the broad sense, managing chronic illnesses and preventing injury, and encourages people to take responsibility for their own health, while offering them support.

Via SSF, Health Canada contributed $30,000 in start-up funding used to hire an architect, hire a consultant to survey the population about their immediate and future needs, produce an information brochure and promote the project with a view to obtaining additional funding. The community subsequently succeeded in raising $1.5 million through a door-to-door fund-raising campaign and by organizing events and soliciting assistance from various private foundations and agencies. The province also contributed $500,000 to the project. Today, the community is busy raising the final funds required for this major project, which will have a definite impact on the health of this Francophone minority community.

Major efforts have been made, demonstrating a real commitment by various stakeholder groups and greater responsibility on the part of the communities. One-third of these initiatives are led by regional authorities, one-third by health agencies (hospitals, community centres) and one-third by the community (often via the network itself). Moreover, for all these initiatives, the communities were involved in prioritizing the projects. As well, these initiatives have had an often significant leveraging effect at the provincial level. The PHCTF projects were structured to partner with provincial authorities from the outset. Without wishing to minimize the financial contributions from the provinces, we would like to point out that these projects have also helped involve the provincial governments in improving health services in Francophone minority communities, and by the same token, made their agencies more open to the needs of these communities.

However, when this report was written, the impact of these initiatives was only starting to be felt, given that over half of the projects were still being implemented. Nevertheless, a quantitative analysis reveals a slight improvement in access to certain health services between June 2001 and May 2006, although for almost all the services analysed, close to two-thirds of the 72 regions still have little or no access to services in French. 11

improvement in access

The services showing the most significant improvements are call centres and services for seniors. It is instructive to point out that the involvement of the provinces was crucial for the call centres, and the cooperation of the communities was crucial to services to seniors. Also, we should mention that these developments are consistent with the priorities established by the Committee in 2001: prevention/promotion, primary care, seniors and children.

Overall, we estimate that while in 2001, over 50% to 55% of Francophones in minority communities never or rarely had access to services in their language, as of May 2006, that figure had dropped to approximately 45% to 50%.

Key challenges in improving access to services

The consolidation and creation of access points are definitely powerful levers in improving health services for Francophones in minority communities. The PHCTF projects represent a modest beginning, however at the same time they offer a great deal of hope. Nevertheless, some major challenges must be addressed if the momentum is to be maintained.

  • Mobilizing agencies responsible for services. The continuity or sustainability of most of the initiatives undertaken require support to be maintained or renewed over time. To foster this support, PHCTF projects were successful in getting all the parties involved and giving key stakeholders responsibility for leadership of the initiatives. To ensure that the measures undertaken continue, we will have to continue involving the authorities responsible for these services by demonstrating the benefits of these initiatives.
  • Prioritizing projects. Needs will very probably continue outstripping available resources, meaning that each community will have to clearly identify the most important projects based on their specific needs and the priorities of the health authorities.
  • Achieving project synergy/complementarity. Although the fact that resources are limited means prioritizing some projects, at the same time it is important to avoid unnecessary duplications, combine some efforts, share lessons learned and best practices among communities, and so on. In recent years, this aspect has played a lesser role in the project selection process because it was important to get momentum going in all regions and the projects were limited in scope.
  • Developing models adapted to the various communities. The solutions for improving the situation of Francophones in minority communities are not unique. The need to adopt approaches based on the community in question is based on a number of factors: the different sizes of communities, different population densities, different health situations, different demographics, different resource availability, and so on. As a result, we have to develop service delivery models that are adapted to the specific characteristics of the various communities.

Technology achievements

Although no budget was earmarked specifically for the technology lever, some of the initiatives described above and funded by the PHCTF, particularly those involving remote access, have a technology component. However, the full potential of this lever, particularly with respect to access to health services for remote or rural Francophone minority communities, has not been realized within federally funded activities. As we will see, this lever generally requires major investment and must be implemented in close cooperation with the provinces, which constitutes the major challenge for this lever. The needs of Francophones in minority communities must be integrated within technology initiatives targeting an entire province or territory. In short, we have to make sure that the Francophone component is included when preparing health technology initiatives and that it is seen as a proven opportunity.

Implementing conditions that faciliate the desired changes

In short, since 2003, through federally funded activities, a number of "facilitating" conditions have been developed, including concerted effort by the five main partner groups, the involvement of training institutions, improvements in the legal framework, the development of promising relationships with the provinces, the emergence of research data, and the increased participation of communities. These conditions were also the cornerstones of the Committee's 2001 strategy for achieving the strategic objectives. Midterm, we are seeing greater awareness on the part of Francophone communities, involvement of partners, recognition of networks as credible representatives able to bridge the gap between community needs and health care systems, and the creation of development plans by the provinces. Moreover, the approach implemented in 2001 has been recognized by the Network Towards Unity for Health (TUFH), affiliated with the World Health Organization, as an innovative approach that meets community needs.

Furthermore, through their activities, the SSF and its networks have been catalysts, developing promising initiatives for increasing resource visibility and actively offering services, while the activities of the CNFS and its member institutions have produced and continue to produce an increase in the number of available professionals by offering initial training and professional development via continuing education.

These funded activities have created the desired momentum and appear to be still relevant today. However, several major obstacles remain in terms of availability of professionals, visibility of resources and still-limited access to services. It will therefore be essential to capitalize on the efforts made to date, and in some cases refocus in order to do more, and ideally, more quickly.

funded activities

Overview of the strategy and recommended adjustments

There is no doubt that access to French-language health services is better in 2006 than it was in 2001. Significant progress has been made in a short time.12 The results of various achievements stemming from the 2003 Action Plan initiatives have played a role in this. However, it is also obvious that even greater sustained effort will be required to produce the desired structural changes. By the same token, we must recognize that the current measures had limitations at the outset and still do. For each of the two major objectives, i.e., increasing the availability of Francophone health professionals in the communities and improving access to health services in French, more must be done and in some cases, perhaps done differently.

In updating its strategy, CCFSMC endeavoured to build on recent improvements while identifying the adjustments needed to achieve the target objectives more quickly and more effectively. With this in mind, the Committee defined six sub-objectives for increasing the availability of Francophone professionals in minority communities and improving access to health services in French:

  1. Increase the pool of Francophone health professionals
  2. Promote the placement of graduates in the communities
  3. Attract professionals to the communities and keep them there
  4. Mobilize professionals already in the communities
  5. Educate and involve the community
  6. Develop an active offer of health services.

the comprehensive approach

Sub-objectives 1, 5 and 6 were already explicitly acknowledged in the objectives for the initiatives funded since 2003. Sub-objectives 2, 3 and 4 were not as clearly stated and according to the Committee, deserve attention and specific action.

1. Increase the pool of francophone health professionals

The number of health care professionals has been an issue in Canada for several years and, because of demographic trends, will continue being a key public health problem in the years to come, regardless of the language used by the professional. 13 Consequently, access to French-language health care services in Francophone minority communities is becoming even more problematic and will not be attainable unless all possible avenues for increasing the number of professionals able to provide these services in French are explored. Increasing the availability of Francophone professionals requires action addressing all potential pools, i.e.:

  • increasing the number of Francophone students registered in French-language training institutions;
  • identifying Francophone students registered in English-language training institutions;
  • increasing the number of existing professionals able to/interested in upgrading their skills;
  • providing immigrants with health training opportunities.

Up to now, the CNFS project has focused on the first potential pool of new health professionals able to communicate in French, and to a lesser degree, on additional training for existing professionals. Although these efforts must continue and even be strengthened, other measures or initiatives are also appropriate if we are to do more, more quickly.

Francophone students registered in French-language training institutions

The CNFS is exceeding forecast expectations as its 10 member institutions and their partners increase enrolments in health training programs and create new health training programs. However, to ensure that those efforts and partnerships continue producing results, attention in the coming years must be paid to:

  • Continuing the various training programs implemented by CNFS member institutions and increasing the number of enrolments in the proposed programs. The benefits of the efforts made in recent years to develop courses and increase enrolments has only begun to produce more graduates. We must take maximum advantage of the investments made since 2003.
  • Developing new French-language training programs and establishing inter-institution partnerships. Efforts in recent years have resulted in the development of a number of programs. Improving health services in Francophone minority communities means considering a wide range of qualifications, and that requires continuing to expand competencies to also cover certain needs that are important to a number of communities. This will require not only developing new programs, but in several cases, considering new partnerships between institutions.
  • Increasing the number of programs and courses in regions that do not have accredited training in their provinces. Experience in recent years shows that the geographic origin of students registered in CNFS programs does not yet fully meet the needs of the communities, and that it has been difficult recruiting students who live a long way from CNFS member institutions. We must continue efforts to bring CNFS institutions and programs to the communities by delocalizing program components and offering more distance education.

Francophone students enrolled in English-language training institutions

In some regions with fewer French-language training institutions, for example, Western Canada, it would also be appropriate to capitalize on the pool of Francophone students trained in English-language post-secondary institutions, 14 given that CNFS members institutions do not offer some types of health training. This pool cannot be ignored because it increases the number of health professionals able to express themselves in French and increases the likelihood that students will stay in their communities after graduation. The goal is to "recover" these graduates or interest them in settling in Francophone minority communities.

However, achieving this goal means better identifying Francophones enrolled in English-speaking institutions, being able to provide them with the means and environment enabling them to practice their profession in French, as well as encouraging them and helping them work in a Francophone environment once their training has ended. However, this avenue must be consistent with the objectives of the CNFS member institutions. This would require closer ties between the networks, English-language training institutions and CNFS member-institutions in order to identify and support Francophone students, develop new ways of recruiting and retaining them in order to facilitate their transition to a French-speaking work environment, as well as encouraging them to stay in Francophone communities and helping them make that transition.

Existing professionals able to/interested in upgrading

Health professionals already working in Francophone minority communities are extremely valuable assets. Some of these professionals want to upgrade their professional skills and/or acquire the knowledge they need to deal with problems that arise in their communities. Others want to move into a new health care specialty, ideally in an area of need for the community. Finally, a number of professionals able to communicate in French but trained in English and working mainly in English-speaking environments could benefit from training on French terminology specific to their area of practice.

Since the CNFS was created, its member institutions have developed an additional 181 days of non-credit continuing education, thus generating 5,221 student days of continuing education. Although the scope of this training is significant, the continuing education and professional development sector was not a priority in the previous plan and, as a result, is in the initial phases. This tool is nevertheless very relevant and effective, and requires additional emphasis to enhance the skills of Francophone graduates and thus reduce shortages.

In January 2006, the CNFS completed a study15 that included a survey of 549 Canadian health care professionals on clinical and continuing education needs. Respondents cited several factors in the decision to attend a continuing education course:

  • Language: all respondents are interested in French language training.
  • Accessibility: the respondents prefer easily accessible training sessions (in person or using technology) owing to personal, family and professional obligations.
  • Relevance: the respondents are interested in training relating to their profession and work environment and which reflects their region's characteristics.
  • Adapted to work schedules: the respondents definitely want continuing education courses given on site, in their region and adapted to their work schedules.
  • Costs: Most respondents believe that their employers should contribute to training costs, failing which training should be affordable.

Immigrants with health training

The integration of qualified French-speaking immigrants within Francophone minority communities is an important means for rapidly increasing the number of Francophone health care professionals in minority communities, at a reasonable cost. Health-care training, often of short duration, can be a strong incentive for these new arrivals because it offers them rapid access to the labour market, and often opens the door to further training in the health professions. 16 The Canadian government is well aware of this opportunity and even made commitments in its 2006 budget, proposing the creation of the Canadian Agency for the Assessment of Foreign Credentials. However, questions regarding the specific mandate of this agency remain a concern as well as the lack of access to professional upgrading programs in French.

To date, efforts in this area by the CNFS and SSF have not been sufficient, and we are a long way away from taking full advantage of this potential pool of health care professionals. However, the provinces and territories, as well as the federal government, have taken a number of promising steps. Nevertheless, this is a complex issue and requires the involvement of specific stakeholders (professional orders/associations, government immigration authorities, provincial health departments, and so on). The challenges in this area were reiterated recently in the CNFS Formative Evaluation:

  • New arrivals face enormous problems getting their credentials and experience recognized, and efforts to address this problem are insufficient.
  • Refugees enrolled in health care training programs often come with experiences that have long-lasting consequences, and they need support programs.
  • Many Francophone immigrants do not speak English, which is often a barrier to clinical internships or jobs in predominantly English establishments.
  • The institutions needs more tools for bridging cultural gaps, better understanding the socio-cultural realities of immigrant students, and ensuring that recent immigrants become familiar with Francophone culture so that they can interact effectively with French-speaking patients.

We must also remember that the integration of these new arrivals is a two-way street. The community must also make an effort to attract these professionals and show them that they are valued. This means overcoming the various obstacles and developing credential assessment, upgrading and integration programs in order to draw on this pool of possible professionals who have the potential to settle in and enrich Francophone minority communities.

For each of the four challenges listed above, considerable effort is required to ensure that these new professionals want to work in Francophone minority communities. As we will see in the next section, it is not just a question of training professionals; we also need to implement promising strategies for successfully recruiting and retaining professionals in regions with needs.

2. Promote the placement of graduates in the communities

Training new Francophone health care professionals will not have the desired impact unless they go on to practise in Francophone minority communities. Placing graduates in these communities is thus key to achieving the objective of having health care professionals available in the communities. This requires paying attention to:

  • the geographic proximity of training activities;
  • the geographic location of internships and experience;
  • the geographic origin of students enrolled in training programs;
  • the existence of financial and non-financial incentives for coordinating and updating internships.

CNFS member-institutions have worked hard in recent years to develop internships in Francophone minority communities. Other valuable initiatives (for example, scholarships offered by a group of Alberta doctors for young people in their region to train and return to the region) or new approaches used by the training institutions (for example, Collège Boréal's introduction of health training programs in five new regions in north and south Ontario, or the use of financial incentives by various training institutions, such as the University of Ottawa, to get graduates to return to their region of origin) are steps in the right direction, but much more will be needed.

Geographic proximity of training programs

Experience in the field and research have shown that the location of post-secondary studies is important in a professional's choice of location of residence after graduation. Consequently, having some or all of the training delivered in Francophone minority communities significantly increases the chance that graduates will return to or stay in the region. Obviously, it is and will remain impossible to decentralize training to all communities. However, steps can be taken to facilitate return/retention as frequently as possible. As mentioned above, CNFS member-institutions already cover several regions across a large part of Canada, and some institutions have taken additional steps to delocalize some of their training programs. Setting up existing programs in new regions geographically expands the supply of French-language training. Distance training initiatives developed by some CNFS member-institutions are another way to provide conventional training and continuing education near the communities in question. However, more can be done to encourage those institutions that have already taken steps in this direction. Existing courses should be advertised more extensively, based on community needs, and this should be an integral part of the next strategy. Finally, considering French-speaking students enrolled in English-language institutions is another way of achieving the desired result.

Geographic location of internships and experience

Several health training programs require one or more internships in health care institutions. Offering clinical internships in the community is a winning strategy for getting students to return or settle in Francophone minority communities. Accordingly, by the midway point, the CNFS had developed 198 clinical internships in Francophone communities, which is more than the 100 originally planned. Also, the University of Ottawa has developed clinical supervision modules to train more internship preceptors. To date, the program has 503 students registered in the on-line program and 390 in the classroom program. However, there is broad agreement that French-language and bilingual clinical training opportunities must be expanded further. On the one hand, the development of certain programs is still being restricted by the number of internships, and on the other, it has been difficult to find internships in all students' regions of origin owing to the scarcity of French-language or bilingual establishments.

Furthermore, based on the experience of the Association of Faculties of Medicine of Canada (AFMC), which has developed a project comprising 40 internships in Francophone minority communities, elective internships and summer internships are better suited to French-language internships in minority communities than regular non-residential internships and residencies, because it is more difficult to influence students' choice of location once they have graduated. 17 In short, student awareness and interest has to be stimulated earlier on. Moreover, the AFMC's experience shows the importance of providing internship opportunities in the student's community or province of origin.

This requires building partnerships between training institutions (French- and English-speaking, near a Francophone minority community) and the care facilities and communities in order to identify potential preceptors, inform students at the appropriate time, develop new internship sites and train additional preceptors. Professional associations can also play an important role in identifying potential preceptors and clinical sites. These partnerships are also essential to increasing awareness of the health status of Francophone minority communities and involving them in meeting the needs of these communities.

Geographic origin of students

The geographic origin of students plays a major role in the choice of establishment. Naturally, the probability of recruiting and retaining a new graduate in a minority community will be much higher if the student originates from the region. And of course, it is not easy for training institutions to select students based on the needs of their home communities; selection is based on the applicant's academic record and achievements. However, a number of initiatives have shown that it is possible to set aside places for students from particular regions with no harmful effect on the quality of the results or graduates. It is important that CNFS institutions, in particular the coordination services, continue to be aware of the student origin aspect and continue their efforts to recruit applicants from regions that do not constitute a "natural" applicant pool, and even propose reserving spots in some member institutions.

It is also up to the community and health authorities (including the establishments) to encourage young people in their communities to consider careers in the health sector.

The existence of financial and non-financial incentives

More can also be done to encourage young people in minority communities to enter the health professions or return to their home regions by developing incentives (scholarships, competitions, rewards, paid expenses, recognition and appreciation, integration support, and so on). Financial incentives are considered to be a factor in recruiting medical students for internships in minority communities.18 Furthermore, the financial incentive approach has been used successfully by some CNFS member-institutions, and by some communities. 19 And we should not forget all the non-financial measures that may make minority communities more attractive to new graduates. As we will see in the next section, these measures are extensively used by the institutions to recruit new professionals, and can involve support for getting settled in the community, professionally and personally, recognizing their contribution and supporting their activities. However, this lever (financial and non-financial), has not been fully exploited because of a lack of funding.

Obviously, combining several of these measures is a winning strategy, for example, encouraging young people to pursue careers in the health sector, having them do some of their training nearby, offering clinical internships close to home, and keeping them in the communities by using various retention incentives. This last item should not be ignored, and is covered in the next section. Also important is using an approach in which the training institutions "push" and the communities "pull."

3. Attracting and retaining health professionals in the communities

Communities must also come up with ways of recruiting and retaining the Francophone health care professionals they need. To date, the initiatives supported by the 2003 federal Plan have ignored this aspect in terms of Francophone minority communities.20 Leaving aside general awareness-building efforts by the networks, few resources have been earmarked for attracting and retaining professionals in the communities. It should be noted that the most promising recruitment and retention strategies are closely tied to the strategies used during training and should continue even once training has been completed.

This means that communities must be sensitive to the needs and expectations of both the "individual" and the "professional." A study conducted to identify the most significant factors affecting the decision to locate or relocate by various professional groups had interesting results. 21 For doctors, the most important factors are:

  • The quality of the professional practice (work atmosphere, professional autonomy, diversity of clients, adequate equipment and facilities, reasonable workload, etc.).
  • Access to continuing education, upgrading and development and any other means to prevent professional isolation.
  • Job opportunities for spouses and the spouse's ability to become involved in the socio-cultural life of the community; these are factors that come up in almost all studies on this topic.
  • The use of financial incentives to recruit and retain doctors is rarely effective on its own, and these measures are more effective when combined with the other recruitment/retention factors, which are clearly more important.

The most important factors for nurses were job-related:

  • Job stability was mentioned most often; full-time status is obviously preferred; permanent part-time jobs are still attractive to nurses with family obligations; casual nurses are attracted to establishments offering stable assignments and guaranteed employment for a specific period of time.
  • The diversity of clinical practice opportunities that allow nurses to make full use of their professional knowledge and expertise; these jobs are more popular than those that are more limited in this respect.
  • Professional support and coaching have declined significantly in recent years, as budgets are cut, however young nurses are looking for employment opportunities that offer this kind of support.
  • Professional development, training and recognition of skills, expertise or experience are very important retention factors.
  • Acceptable workload and nurse participation in organizing workload are also seen as very important retention factors.

Among other health care professionals, the most important factors cited were often related to the work environment, i.e., quality of life in the area, proximity to urban centres, permanent employment, the type of client, job opportunities for spouses, and the cost of housing/cost of living.

Health service managers, professional associations, training institutions and the communities will have to work together closely to develop winning conditions suited to the type of professional required. This is essential, given that retention and, as we will see in the next section, the involvement of individuals, require a combination of favourable elements.

4. Involve existing professionals in the communities

Like recruitment/retention, no specific effort was made during the first phase of the strategy's deployment to involve health professionals. However, all stakeholders agree that French-language services will not be truly available until the professionals are encouraged to express themselves in French. In some regions, working conditions for professionals who speak French (additional unpaid duties, lack of recognition, risk of career stagnation, lack of opportunity to practice speaking French, and so on) are not conducive to working with the Francophone population. We have to ensure, wherever possible, that efforts made to train and recruit valuable resources are not wasted, in part or in whole, because the environment is not conducive to providing services in French.

This means making every effort possible to create this type of environment. The community and its representatives (the networks, for example), should pay close attention to the needs/frustrations of their Francophone professionals and finds ways to overcome their problems while valuing the role they play. Health care institutions must limit the number of job-related and career irritants, while making it possible for professionals to become comfortable enough to practise their profession in French. Professional associations and training institutions can also become more active in this area by playing a major role in effective networking among Francophone and Francophile health care professionals across the country, via various social activities, continuing education, sharing of best practices within a minority community context, and so on.

5. Educate and involve the community

As pointed out repeatedly in the 2001 strategy, community awareness and involvement are essential to improving access to French-language health care services and to sustaining efforts made to date. The Committee identified the foundations for success in this area in its first report, and they remain the same today:

  • concerted effort by the five partners;
  • the development of promising relationships with the provinces; and
  • greater responsibility on the part of the community.

The activities supported by the SSF have resulted in positive progress in each of these areas.

However, to achieve the desired results, these efforts must be continued and in some cases, improved on.

Concerted effort by the five partners

The Committee remains convinced that improving access to French-language health care services will be easier if it is based on the concerted efforts of all major stakeholder groups: the health professions, managers of health institutions, political decision-makers, academic institutions and the communities themselves. Extensive and continuing involvement by each of these stakeholders is required to reduce the numerous obstacles to improving access. It is widely known that managing several health-related issues requires a more holistic and thus more coordinated approach by the various sector stakeholders. A new "system-based" approach is required, rather than the traditional fragmented approach, one based on the World Health Organization's Towards Unity for Health model, the core of which is based on community participation and networking.

However, even if this is the approach to take in renewing our health care systems, getting the parties to work together presents challenges. The health care sector is still highly compartmentalized, and there are still major divisions between a number of stakeholders (cure vs. prevention, biomedical vs. psychosocial, primary care vs. specialist care, public health vs. medical care, the health sector vs. the community sector, and so on). From this point on, getting stakeholders involved, coordinating the efforts of the various partners and reconciling diverging interests will be major challenges. It is and will be very difficult, if not impossible, to make significant improvements in the situation of Francophone minority communities if they each continue to work in isolation. Given the limited availability of financial, human and material resources, this is a luxury we cannot afford.

In 2001, the Committee acknowledged that realistically, we could not simply count on the volunteer actions of stakeholders or rely on chance to encourage cooperation. The proposed networking initiatives were intended to mitigate these silo effects. Through the efforts of the 17 networks, dialogue was initiated in each province and territory, including all key partners in most cases. The stakeholders involved are in the process of creating solid partnerships based on trust and respect for the skills of each partner22, facilitating the development of a large number of appropriate and high-quality initiatives (including PHCTF projects). Apart from the joint action tables they created, several networks are now also being asked to participate in various forums relating to the health of Francophone minority communities in their provinces.

However, it is also obvious that concerted effort and mobilization varies significantly from one community to the next. Joint action cannot be forced, and is not necessarily a gauge of success.To succeed, networking must be the result of leadership, determination, time and resources. The various stakeholders must be made aware, convinced, encouraged, provoked and ultimately held accountable. Various studies have identified the key characteristics of successful networks, including:

  • strong support from the communities involved;
  • a recognized and legitimate role for each stakeholder involved in the network;
  • an action- and results-based focus;
  • a certain degree of autonomy;
  • a constant flow of communication among the members; and
  • a group of committed individuals, rather than just a group of institutions.

Networks can be implemented and led more easily if the stakeholders in the field are responsible for the network and devote the necessary time to it, hence the importance placed on supporting network coordinators. These individuals must be energetic and skilled in certain areas (knowledge of the health care sector, strong leadership skills, the ability to negotiate and solve problems, excellent communication skills, the ability to bring stakeholders together, and so on).

What makes it so hard and even impossible to recruit network coordinators with the ideal profile are the different realities of the various communities. Also, it has to be admitted that the budgets earmarked for coordination and their terms and conditions have not made the networks' job any easier. The budgets turned out to be limited and the conditions for awarding funds restrictive. To succeed, more attention must be paid to the profile of the resources, improving their skills and providing technical support, not to mention the degree of operational autonomy of these networks.

Developing promising relationships with the provinces and territories

From the outset, the Committee recognized that the provinces and territories were essential to improving access to French-language health care services. Obviously, they have a constitutional responsibility in terms of health services, but they also play a crucial role in several other areas that are important to achieving the target objectives: social services, education, training, regulating professions, language laws, etc. As mentioned earlier, the development of positive and constructive relationships between the networks and their respective provinces/territories must by the same token be seen as one of the major achievements of the 2003 Plan.

To maintain and strengthen these relationships, the networks must continue working closely with the departments, boards or regional agencies involved. However, these relationships will be more solid if the networks are seen as partners that can help propose and develop solutions. Several provincial and territorial representatives have emphasized the importance they place on this type of contribution, both by their appreciation of activities in recent years and the expectations for the coming years. To achieve this level of credibility and respect, the networks must have the tools they need to act as health advisors and even health experts to Francophone minorities.

In addition to the above-mentioned elements in the profile of competencies and resources dedicated to the networks, we should build further on successes and existing best practices. The limited resources of the provinces/territories and the numerous pressing needs in the health sector, and the possibility of going further more quickly, require disseminating information more widely and paying more attention to innovative solutions. The national coordination bodies can play a part in this, but research efforts could focus more on these aspects. Research can be a formidable tool in building awareness and collaborating with government authorities, both to assist in setting priorities and to support the development of the best service delivery models. To have an impact on access to health services however, research must be applied, action-based and rooted in the needs of the communities. In this respect, we must note the constructive contribution of the joint research commission headed up by the CNFS and SSF, which is structured to bring together researchers interested in the health-related problems of Francophones in minority communities and ensure that the work that is supported assists in decision-making. Three themes have been identified as priorities: the impact of language and culture on health, health determinants, and governance (priorities, service delivery models, etc.).

Despite this commendable direction, however, it is still difficult to define priority areas of research and get key actors to recognize them as such. Additional effort will be required to define and disseminate a vision for research on the health of Francophone minority communities, to promote that vision to widely dispersed health researchers and interest them in studying the communities, and finally, to raise the awareness of funding agencies so that they will support research that meets the communities' needs.

Greater responsibility on the part of the community

It is increasingly recognized that involving individuals and communities in taking responsibility for their health is a more efficient and effective approach. The Setting the Stage project,which focuses on service planning by the community, or PHCTF initiatives, which are prioritized and in several cases developed by the community, are steps in the right direction. The development plans will provide an overview of the needs of Francophone minority communities and health delivery models adapted to those needs. In all the provinces, this planning effort has been seen as a positive step, and community involvement has also impacted the well-being of individuals, i.e., provided a sense of belonging to Francophones in minority communities, which in turn facilitates cooperation and involvement in the initiatives that goes beyond the formal health care system. 23 For example, several awareness, prevention and health promotion initiatives have been implemented.

If they are to maintain and strengthen this move to take responsibility, the networks must continue to act as credible facilitators in planning services and continue getting the various communities agencies in their regions involved.

6. Develop an active offer of health services

Ultimately, improving access to French-language health services must involve:

  • enhancing knowledge and visibility of the offer of services; and
  • developing service points.

By 2001, it had already been acknowledged that developing access to health services for Francophone minorities not only required working on the offer of services, but making that offer of services more visible, and indeed proactive. Several of the initiatives implemented since 2003 have increased that visibility, however, the results in terms of developing new service points and the proactive offer of services are still limited.

Enhancing knowledge and visibility of the offer of service

As indicated earlier, a number of PHCTF projects have focused on enhancing knowledge of the offer of services in French and better visibility of available resources. Often, by using on-line or print directories, and through improved advertising of the availability of Francophone human resources and services in hospitals, for example, these initiatives have helped Francophones in minority communities get a better idea of what is available to them. This effort should not be minimized, given that these tools not only indicate whether or not French-language services are available, they can also be used to reinforce and value professionals able to express themselves in French.

This investment in information-gathering will not reach its full potential, however, unless the directories are used and are useful. To be used, they must be marketed. However, promotional efforts have been very uneven, thus reducing the impact of this tool in certain communities. To be useful, the information must be updated on a regular basis, a fundamental aspect that requires resources to be assigned to following up on these initiatives. Although governments are obviously concerned about this need for continuity, the communities, professional associations and training institutions should also be part of this effort.

Developing service points

Under the PHCTF, considerable resources have been invested in developing the offer of French-language services. Despite the fact that most of these projects are still not completed, we can expect several of them to have a major impact in the communities supporting them and in some cases, funding them. This success stems in large part from the procedure that was followed, i.e., a commitment on the part of all the parties involved, and an alignment with the communities priorities including, obviously, those of the provinces and territories. However, it is also obvious that there is still much to be done to substantially increase the level of services available in French.

However, as pointed out in 2001, not all Francophone communities can aspire to the same level of French-language services. The size and population density of some communities do not allow for the development of a full range of services, or in some cases, even an expanded range of services. Nevertheless, a number of solutions can be adapted to smaller communities, particularly in terms of prevention/promotion and primary care. The experience of recent years again confirms the immense existing potential, to say nothing of the options offered by new technology.

PHCTF projects have also revealed certain major challenges in developing new intake facilities, particularly when financial resources are limited:

  • The importance of consistency with the priorities of the provinces and territories. Jurisdiction over the delivery of health care services rests first and foremost with the provinces and territories. The health sector already has considerable needs, which tend to outstrip the resources that the provincial/territorial governments can devote to them. It is therefore important that the proposed solutions for improving access to health care services in French be clearly aligned with the directions, choices and priorities of the provinces and territories. This is particularly important for technology-based initiatives (telehealth-type initiatives) and more capital-intensive initiatives (hospital care). As mentioned above, the Setting the Stage project may be an excellent lever for identifying and supporting the choices of the provinces and territories. The PHCTF projects that have co-funded certain provincial/territorial initiatives are a step in this direction.
  • The importance of developing innovative solutions adapted to small communities. Involving the provinces and territories will be easier if new and more effective and efficient approaches are developed. There are several highly interesting initiatives underway in various communities/provinces/territories, e.g., primary care services delivered via the Francophone school system, itinerant services, or again, innovative groupings of health professionals. The value of these ways of organizing services stems from the fact that provincial/territorial health departments and/or agencies are not being asked to provide significant resources.
  • The need for more effective synergy among the various initiatives. In recent years, each community has sought to develop their own initiatives, and while this approach helped get the momentum going by mobilizing and involving the community, in the coming years we will have to take maximum advantage of each of these initiatives. Wherever possible, we must avoid duplicating efforts, consider more multi-community initiatives, integrate all the initiatives undertaken in each community, expand projects that have the capacity to become Canada-wide initiatives, and share best practices or knowledge transfers more effectively.
  • The need for a more streamlined and shorter budgeting and project approval process. The budgeting process used for PHCTF initiatives has proven dysfunctional in several respects. The piecemeal funding approach, together with item-by-item payment terms and conditions has led to major implementation delays, significant efforts devoted to budget administration and sometimes sub-optimal allocations in terms of target results. All the parties are aware of this dysfunction, including the senior officials responsible for this file at Health Canada. Future measures must correct this situation.
  • The development of indicators for measuring developments in access to health services by Francophone minorities, including prevention and health promotion variables. The Committee has had problems measuring developments in the situation since 2001, as did several networks for the Setting the Stage project. This situation must be remedied in order to plan the offer of services more effectively and adjust it as needed.

As we can see, the Committee believes that positive momentum was achieved, but that limited improvement has been made in access to French-language health services. The initiatives implemented to date have achieved results that are consistent with the objectives, however, ongoing and in some cases new efforts are required. In the next section, we address the issue of priorities and summarize the Committee's main recommendations to the federal Minister of Health.

Priorities and recommendations

Despite considerable effort in recent years, the renewal of health systems is still on the agenda of practically all national and regional governments, in Canada and around the world. Demographics, technological developments, public expectations and public finances, to name but a few, continue putting significant pressure on the systems and the organization of health services. The Consultative Committee for French-Speaking Minority Communities (CCFSMC) is still convinced, as it was in 2001, that this difficult context can also be seen as an opportunity to adopt innovative approaches.

Progress achieved since the first report shows that improving the quality of health services for Canada's one million French-speaking citizens living in minority communities is fully attainable, despite the challenges and constraints of that objective. The CCFSMC is even more convinced today that the success of its initiative depends on approaches that focus on mobilizing and coordinating resources in order to facilitate the implementation of more effective disease prevention and health promotion strategies. These approaches require the combined support of the federal government, provincial/territorial governments, the communities themselves, health care professionals, health care establishments and training institutions. In addition to prioritizing the adjustments needed to ensure that more is done, more effectively and more quickly, the Committee believes that we need to reiterate a number of factors that are essential to achieving its mandate.

Foundations of the proposed directions

Based on the experience of recent years, the CCFSMC has reaffirmed or identified a number of foundations that are key to successfully improving access to health services for Francophones in minority communities. These are:

  • the measurement of results;
  • the essential involvement of the provinces/territories;
  • the leveraging role of the federal government; and
  • the cooperative approach of health partners.

The measurements of results

When preparing its report of achievements, the Committee was again confronted with the lack of certain basic information that would have made it possible to evaluate developments in access to health services for Francophone minority communities. Furthermore, despite the fact that all the funded initiatives had specific objectives, a number of the relevant results were not the subject of explicit objectives, and consequently the data required to measure them was not gathered. This situation must be remedied by better defining target results and at the same time, acquiring the tools to measure them appropriately. To make this a reality, the Committee intends to play a broader role in establishing objectives for the various initiatives funded by the federal government and establish a comprehensive evaluation framework for its strategy. This framework would focus on measuring the major strategic objectives selected by the Committee (see page 16).

The essential involvement of the provinces and territories

In its first report in 2001, the Committee reiterated that the provincial and territorial governments had primary responsibility for managing and improving health care systems, and stressed the crucial need to develop methods for cooperating closely with the provinces and territories. The design and implementation of PHCTF projects in which the provinces and territories were directly involved, the structure and objectives of the various networks created that included the explicit goal of establishing positive relationships with the provinces and territories, and indeed the composition of the Committee and the development of its directions, which involved provincial and territorial representatives, are a few concrete examples of this willingness. We must also acknowledge that several provinces and territories have directly contributed to recent improvements in the situation of Francophone minority communities by financially supporting joint initiatives or implementing certain promising measures on their own. Recent experience also confirms that the more sensitive the provinces and territories are to the needs of Francophone minority communities, the greater the effort and initiatives. The Committee reaffirms the importance of continuing in this vein and ensuring that the proposed solutions, particularly those for improving French-language service points, can be effectively aligned with the provinces' directions, choices and priorities.

The leveraging role of the federal government

The Canadian government recently reaffirmed its commitment to "enhancing the vitality of the English and French linguistic minority communities in Canada and supporting and assisting their development..." It is obvious that health is important to the vitality and development of Francophone minority communities. Through its responsibilities in the areas of disease prevention and health promotion, or more broadly, public health, the federal government can contribute directly to the well-being of Francophone communities. Recent experience also shows that the federal government can play an even greater leveraging role in the health of these communities by respecting the sharing of constitutional jurisdiction. The initiatives funded in recent years by the federal government have led to additional investments by the provinces/territories and communities, facilitated official recognition of Francophone community authorities, led to the integration of the needs of these communities into the planning and organization of regional services, made the partners aware of the importance of language to the quality of health services, and so on. Given greater public support for official languages and the broad support for health initiatives, combined with the willingness of the federal government to develop new partnerships with the provinces/territories and the importance of its contribution to this issue, the Committee believes it is essential that the federal government further capitalize on its leveraging effect and play a leadership role in improving access to health care services for Francophone minority communities.

The cooperative approach among health partners

All of the stakeholders obviously have an interest in meeting this ambitious challenge of improving access to French-language health services. The Committee remains convinced that the viability and effectiveness of health care systems depend on real cooperation among the key partners. The World Health Organization model, Towards Unity for Health, is still just as relevant today. According to this model, the optimal performance of a health care system in terms of the well-being of the population requires the concerted participation of the five main partners: the health professions, managers of health institutions, political decision-makers, academic institutions and the communities. In view of the achievements made in recent years, we are convinced that this direction is the one to take. It is also preferable that this cooperative approach be implemented at the local, regional and national levels.

Recommendations and priorities

Based on the experience of recent years, the CCFSMC has reaffirmed certain directions, but also suggested some adjustments. In this respect, we submit the following recommendations to the Minister of Health.

Recommendation 1. Continue efforts made in recent years to improve the health of Francophones in minority communities. Based on the experience of the past three years, we have built on several of the conditions essential to achieving the target results. Several concrete measures that will produce the desired improvements are underway. Even a partial withdrawal by the federal government could, at this stage, interrupt the current momentum, reduce community involvement, and compromise or even result in the termination of some initiatives, while irritating provinces or territories engaged in strategic activities with their Francophone communities.

Recommendation 2. Maintain primary health services as a priority, with seniors and children as priority client groups. These clients groups are the most vulnerable and the lack of health services in their languages impacts them the most. In terms of types of care, all stakeholders recognize the importance of primary health care services to improving individual health, and to the quality and effectiveness of the system. Recent reforms in provincial and territorial health care systems have also recognized the critical role of these services.

Recommendation 3. Work on the five identified levers (networking, training, access, research and technology) but give priority to the first four. In recent years, efforts have focused mainly on the first three levers, i.e., those that had the greatest immediate impact on key services and target client groups. From a perspective of medium-term improvement, we now need to include research as a priority lever, which will allow us to measure results more effectively and better characterize the service models that best meet both the needs of the communities and the needs of the government departments responsible for health services.

Recommendation 4. Do more, and in some cases, do things differently for each of the two major intermediate objectives (increasing the availability of Francophone health professionals in the communities and improving access to health services in French). Specifically, this means focusing on all available pools of new Francophone professionals. The Committee still believes that the greatest potential lies with Francophone students enrolled in health programs in Francophone institutions, but more effort will be required in coming years to interest Francophone students enrolled in English-language institutions, as well as qualified Francophile immigrants, in settling in Francophone minority communities. Similarly, initiatives for attracting and retaining health professionals must be increased, and by the same token, efforts at encouraging and mobilizing the health care community must be expanded, particularly in terms of service points and professional associations. Also, the types of training that are funded should be better aligned with the priority needs of Francophone minority communities. Finally, the development of a truly active offer of French-language health services is still a priority and, as a result, the resources devoted to implementing new and effective models for delivering these services and for disseminating these models must remain equal to the challenges facing us.

Recommendation 5. Help community institutions achieve target objectives effectively. To date, two major strategic initiatives have been supported: the Consortium national de formation en santé (CNFS) and the Société Santé en français (SSF). This dual structure was adopted to reflect the specific characteristics of both training institutions and local communities. The CNFS and SSF very quickly identified common issues and created joint committees for addressing these issues. Based on recent experience, we believe that this dual structure is still appropriate for stimulating the desired level of involvement among the target communities and facilitating achievement of the target objectives. However, it is also obvious to the Committee that joint issues are becoming both more numerous and more important, particularly in the area of human resources. We believe it would be a good idea to explicitly recognize this need for close alignment by establishing a number of objectives that are common to both organizations.

Recommendation 6. Further integrate professional associations within the strategy. Increasing the number of health professionals settling and staying in Francophone minority communities requires establishing close relationships with the individuals offering these services. The CNFS and SSF have been very sensitive to this need in recent years and have built bridges in specific areas. However, the Committee believes that these relationships must become more intense and sustained in order to create all the conditions essential to achieving the desired results. Obviously, this means more effectively integrating the orders and associations that accredit and represent the various health professions, particularly those representing doctors and nurses.

Recommendation 7. Devote the appropriate financial resources to achieving established objectives and ensure that their terms and conditions are straight-forward as well as results-based. Federal funding has acted as an important lever in recent years, and is the preferred approach for the next phase of the strategy. However, the budget approval and tracking process for certain programs was particularly cumbersome and adversely affected certain projects. These adverse effects can be mitigated via close cooperation and effective information sharing between the Department and community institutions, while continuing to comply with legislation and regulations governing the administration of public funds.

The challenge of improving the health of Francophones in minority communities can be met successfully only if governments are open, institutions and health professionals are involved and Francophone communities take action. The Committee's approach is designed to develop this momentum for change. It is asking the Francophone minority communities, with its health partners, to take responsibility for and take action to improve access to health services in French in their communities.

To succeed, the Committee is counting on new leadership from all interested parties, leadership that will result in improved health for Francophones in minority communities and in the further development and vitality of these communities.

Members of the Consultative Committee for French-Speaking Minority Communities

Hubert Gauthier
Community Co-Chair
President, Executive Director
Société Santé en français

Marcel Nouvet
Health Canada Co-Chair
Assistant Deputy Minister
Corporate Services Branch
Health Canada

Paul-André Baril
Community Co-Secretary
Networks' and Government Relations
Société Santé en français

Pascal Milly
Health Canada Co-Secretary
Official Language Community Development Bureau
Health Policy Branch
Health Canada

Community Representatives

Jean-Guy Rioux
President
Fédération des communautés francophones et acadienne (FCFA)

Jacques Schryburt

Retired, Ottawa

Dr. Denis R. J. Vincent
President, Réseau santé albertain

Anna Veltri
Collège du Savoir, Brampton

Dr. Aurel Schofield
New Brunswick Francophone Medical Training Coordinator

Anne M. Leis
Associate Professor
Department of Community Health and Epidemiology
University of Saskatchewan

Andrée Lortie
President, La Cité collégiale
Ottawa

Health Canada Representatives

Frank Fedyk
Acting Assistant Deputy Minister
Health Policy Branch

Roger Farley
Executive Director
Official Language Community Development Bureau
Health Policy Branch

Laurette Burch
Regional Director General, Manitoba and Saskatchewan

Chantal J Morin
Director General, Human Resources
Public Health Agency of Canada

Canadian Heritage Representatives

Jérôme Moisan
Senior Director, Official Languages Secretariat

Louise Trahan
Director, Interdepartmental Coordination

Provincial Representatives

Manitoba

Guy Jourdain

Senior Advisor
French Language Services Secretariat

New Brunswick

Lyne St-Pierre-Ellis
Medical Resources Advisor
Department of Health and Well-Being

Alberta

Denis Tardif
Director
Francophone Secretariat

1 Please note that there is also a separate Anglophone committee mandated to address access to health services in English in Quebec and liaise with the Department and Anglophone minority communities in Quebec.
2 This research was done for the Committee during the spring and summer of 2006 by SECOR-TAKTIK.
3 See the appendix to the FCFA report, Pour un meilleur accès à des services de santé en français, 2001.
4 Source: FCFA, Pour un meilleur accès à des services de santé en français, 2001, p. ix
5 Source: FCFA, Pour un meilleur accès à des services de santé en français, 2001, p.37.
6 When the Committee's report was tabled in 2001, there was only one regional network in the country, the Réseau des services de santé en français de l'est de l'Ontario.
7 Decima Research, The Evolution of Public Opinion on Official Languages in Canada, prepared for the Office of the Commissioner of Official Languages, September 2006.
8 Report on the Formative Evaluation of the Health Care Training and Research Project by the CNFS, March 2006.
9 This agreement has had unexpected impacts by opening places to students from other Atlantic provinces (e.g., Nova Scotia and Prince Edward Island) and even from the Western provinces (three places per year for students from these provinces).
10 See second Rapport sur la santé des francophones de l'Ontario, by Public Health Research Education and Development and Institut franco-ontarien, December 2005.
11 Although not perfect, this analysis provides an update on some data gathered in 2001 for CCFSMC's first report.
12 Progress recognized, for example, by Health Canada. Moving Forward in the Health Sector, Status report, Consultative Committees for English- and French-Speaking Minority Communities, October 2005.
13 In June 2000, the Department of Human Resources and Skills Development (HRSDC) was already predicting shortages at that time and over the next five years in the following sectors: nurses, anaesthesiologists, surgeons, etc.
14 For example, according to the PHCTF project implemented by the Association of Faculties of Medicine of Canada, the faculties have, on average, one to four students per cohort who come from Francophone minority communities (excluding the Sherbrooke and Ottawa faculties).
15 Study on clinical training and continuing education needs of health care professionals in Francophone minority communities, CNFS, January 2006.
16 For example, a number of immigrant students registered in the health care worker program report that once they obtain this initial certificate and are established in the labour market, they plan to continue their studies in college or university programs. Source: Report on the Formative Evaluation of the Health Care Training and Research Project, CNFS, March 2006.
17 Source: Physicians and Care of Quality for Canadian Francophone Minority Communities, Project evaluation, June 2006.
18 Paid transportation and accommodation were identified as incentives to medical students to do internships in Francophone minority communities (see final report on activities and results of the projectPhysicians and Care of Quality for Canadian Francophone Minority Communities coordinated by the Association of Faculties of Medicine of Canada, July 2006).
19 For example, a clinic in Ste-Anne, Alberta contributed financially to training expenses for young people who committed to returning to the community.
20 Although these types of initiatives were identified as a priority by the Consultative Committee for English-Speaking Minority Communities.
21 Study by SECOR Conseil for the Régie régionale de la santé et des services sociaux de l'Outaouais.
22 See, for example, Health Canada, Moving Forward in the Health Sector, Status report, Consultative Committees for English- and French-Speaking Minority Communities, October 2005.
23 It should be mentioned that over 16,000 individuals participated in various activities (survey, focus group, public meetings, etc.) leading to the plans proposed as part of the Setting the Stage project. This participation helped create a willingness among the partners to take action.

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