Canada Health Action: Building on the Legacy - Volume I - The Final Report
The Right Honourable Jean Chrétien
Prime Minister of Canada
House of Commons
The Honourable David Dingwall
Minister of Health
House of Commons
Prime Minister and Minister:
We the members of the National Forum on Health have the honour to submit our final report, Canada Health Action: Building on the Legacy.
During the months that we have been at work, issues related to health and our health care system have dominated the public agenda across the country. We have heard clearly from Canadians that they deeply value the health care system, and that health and health care are major priorities for them. We have also heard about the significant changes which health care is undergoing across the country.
Based on what we heard and on our analysis, we are confident that the health care system can be preserved through change, and that the health of Canadians can be improved. In our report, we outline the directions which we believe should be taken to accomplish this.
We realize that not everything can be done at the same time. A step-by-step approach with clear directions that are well understood by the public and stakeholders will be key to garnering their support. We would also like to emphasize the importance of cooperation and partnership between governments and with organizations and individuals involved in health and health care, as action is taken.
Given the substantial pressures facing the health care system, and concerns about health status, it is appropriate that this report be provided a year early. We believe that action on our advice will assure the future of the health care system and lead to improvements in the health of Canadians.
Members of the National
Forum on Health
The complete report of the National Forum on Health comprises:
Volume I -
Canada Health Action: Building on the Legacy
The Final Report of the National Forum on Health
Volume II -
Canada Health Action: Building on the Legacy
Synthesis Reports and Issues Papers
Values Working Group Synthesis Report
Striking a Balance Working Group Synthesis Report
Determinants of Health Working Group Synthesis Report
Creating a Culture of Evidence-Based Decision Making
The Need for an Aboriginal Health Institute in Canada
Directions for a Pharmaceutical Policy in Canada
An Overview of Women's Health
As well, the Forum will publish the papers commissioned in the course of its work. The publication of these papers (1997) will provide Canadians with a considerable amount of research in the field of health and health care in Canada.
Table of contents
- A Message from the Members of the National Forum on Health
- Setting the Context
- Priorities for Action
- Preserving Our Health Care System by Doing Things Differently
- Transforming Our Knowledge About Health into Action
- Using Better Evidence to Make Better Decisions
- Mobilizing Our Resources to Move Forward
- Secretariat Staff
A Message from the Members of the National Forum on Health
The Members of the National Forum on Health are pleased to present Canada Health Action: Building on the Legacy, the final report of our deliberations, consultations and research.
In October 1994, the Prime Minister of Canada, The Right Honourable Jean Chrétien, launched the National Forum on Health to involve and inform Canadians and to advise the federal government on innovative ways to improve our health system and the health of Canada's people. The Forum was set up as an advisory body, with the Prime Minister as Chair, the federal Minister of Health as Vice Chair, and 24 volunteer members who contributed a wide range of knowledge founded on involvement in the health system as professionals, consumers and volunteers.
To fulfil our mandate, we focused on long-term and systemic issues. We saw our task as providing advice appropriate to the development of national policies, and we divided our work into four key areas Values, Striking a Balance, Determinants of Health, and Evidence-Based Decision Making. We have built on the excellent work done by provincial governments commissions and studies. The Forum set out to ensure that national priorities are identified and that individuals are involved and informed about the issues and options.
Integral to our work was the dialogue we undertook to hear the views and values of people in all parts of the country. The two phases of our consultation process gave us an opportunity to listen to, hear from and discuss with participants current health and health care issues. Public discussion groups, conferences, meetings with experts, commissioned papers, letters and briefs have all contributed to the Forum's thinking and examination of the issues. We can say with assurance that health and health care have become a defining public issue, and Canadians have an intense interest in this debate, viewing it as a top priority for governments.
Over the past two years, we have become keenly aware of Canadians deep concerns about their health and their health care system and about what they feel is hurting the system. At the same time, people hold a common view of the system they want. They want a flexible health care system that maintains the five principles of the Canada Health Act, is integrated, is supportive of community action, and is driven by information. They will accept change to the system as long as it is accompanied by a plan and they understand what this change is to accomplish. And change is long overdue. The financial environment is making change necessary, but if the system is going to work it needs to change constantly.
Our final report is addressed to governments and the people of Canada. Our recommendations and advice are intended to improve the health of Canadians and to ensure that the health care system is equipped for the challenges of the future. We realize that there are literally hundreds of issues on which we could have provided advice. We took a long-term view on issues that are national in scope and our recommendations set a course for the future, but they call for action now. The final report is supported by a companion volume of working group synthesis reports and papers, and these will be complemented by a series of papers to be released later.
William R.C. Blundell, B.A.Sc. (Ont.)
Richard Cashin, LL.B. (Nfld.)
André-Pierre Contandriopoulos, Ph.D. (Que.)
Randy Dickinson (N.B.)
Madeleine Dion Stout, M.A. (Ont.)
Robert G. Evans, Ph.D. (B.C.)
Karen Gainer, LL.B. (Alta.)
Debbie L. Good, C.A. (PEI)
Nuala Kenny, M.D. (N.S.)
Richard Lessard, M.D. (Que.)
Steven Lewis (Sask.)
Gerry M. Lougheed Jr. (Ont.)
Margaret McDonald, R.N. (NWT)
Eric M. Maldoff, LL.B. (Que.)
Louise Nadeau, Ph.D. (Que.)
Tom W. Noseworthy, M.D. (Alta.)
Shanthi Radcliffe, M.A. (Ont.)
Marc Renaud, Ph.D. (Que.)
Judith A. Ritchie, Ph.D. (N.S.)
Noralou P. Roos, Ph.D. (Man.)
Duncan Sinclair, Ph.D. ( Ont.)
Lynn Smith, LL.B., Q.C. (B.C.)
Mamoru Watanabe, M.D. (Alta.)
Roberta Way-Clark, M.A. (N.S.)
Secretary and Deputy Minister, Health Canada
Michèle S. Jean
Marie E. Fortier, M.H.A., CHE
Setting the Context
Everyone wants good health, but not all are equally healthy. Medical science has made remarkable progress over the last century in finding ways to prevent and treat illness. As a society, we decided that health is a public good and that the costs of treating illness should be broadly shared. To achieve this goal, we built a system we call "medicare". As we learn more about the interventions that work and those that do not, as well as the organizational structures that produce the best results and those that do not, the health care system continually adapts and improves.
Being healthy requires clean, safe environments, adequate income, meaningful roles in society, and good housing, nutrition, education, and social support in our communities. In fact, actions on these broad determinants of health through public policies have led to most of the improvement in the health status of Canadians over the last century. There is still much to do, however, if we want to reduce health disparities among various groups of the population and continue on the path toward better health for all.
Everyone has a stake in health and health care, but many diverse interests are involved. This report is our analysis of the debate, the issues and the opportunities for progress that are available. Over the last two years, we consulted the public to gain a better understanding of their views of the key issues about health and the health care system and the potential solutions. We used what we heard, the research we commissioned, and our own extensive deliberations to develop a perspective from which the issues may be understood and debated, and from which flow the broad priorities for action put forward in the next section of this report.
Canadians Are Concerned
Newspaper headlines regularly suggest that the health care system is in crisis. Conflicts are escalating between health care providers and governments. People see hospitals closing, and they are told that waiting lists for surgery are getting longer and that physicians are leaving the country. Families and friends have to assume more responsibility for care in the home. Governments have frozen or reduced health care expenditures. The private sector is pressing to gain access to new business opportunities in a sector that, up to now, has been beyond its reach. Critics say Canada can no longer afford universal, publicly funded health care. This raises fundamental questions: Can medicare survive? Will medicare be there for our children?
People are also concerned about change in the economic and social environment. Based on our work, we are also worried about the effect of this change on their health. Many believe that Canada is one of the best places in the world to live, but they see worrisome signs of things to come as social tensions rise, intergenerational conflicts emerge, and important issues such as poverty remain unresolved. They fear a society in which a growing number of people are marginalized from the economic and social life of their communities. Some believe governments are retreating from many areas of social policy just when their presence is most needed; others, that governments must first get their financial house in order and improve economic performance. Overall, many feel powerless in the face of large scale change.
We have heard and understand these concerns. Rapid change always raises concerns. It is perfectly understandable that people are worried about losing medicare and about a potential decline in quality of life. We are disturbed, however, that many of these concerns are the result of unplanned or inconsistent action, fear mongering and misinformation. We regret that raising fear among the public is viewed by some as a legitimate way to pursue personal, professional and corporate interests. That being said, we also believe that individuals, families and communities can influence and direct change. Change presents enormous opportunities, and we must turn it to our advantage to secure what we value.
Distinguishing Values, Interests and Opinions
Exploring values has become fashionable in the world of public policy. But it is more than a fad. It is an explicit acknowledgement of the need to be faithful to what people really want and believe in and of the obligation for governments to set policies and allocate resources accordingly. It also reflects the nature of values - running deep, rarely surfacing and revealed only indirectly and imperfectly through the political process. In our quest to separate myth from reality and to cast a critical eye on the spectrum of interests at work, we have also chosen to explore values.
Values tend to be deep-rooted and relatively stable over time. They are also defining characteristics of individuals and organizations. Opinions are more transitory; because they may be developed without much reflection or in response to artificial information or choices, they may be inconsistent with one's values. In recommending a course for Canada's health system, we considered it essential that its foundations be consistent with the values of the majority of the public.
Sometimes, responses to opinion polls conflict with these values. People's views about what needs to change depend on what they see and hear around them, on their immediate personal circumstances, and on the choices offered to them, whether real or not. For example, people will push for more private funding for health care if they genuinely believe it is the only way to "save" medicare; they stand to gain personally from increased private funding; and/or they truly believe that access to health care should be a function of one's ability to pay. Public opinion polls usually do not allow us to probe the reasons why people say what they say. Public opinion has a huge impact on public policy; however, it can be swayed by articulate interests.
In our consultations and discussion groups, we probed people's responses to obtain an understanding of their core values. The findings are unmistakable: the basic principles of medicare accurately reflect people's values of equity, compassion, collective responsibility, individual responsibility, respect for others, efficiency and effectiveness. In fact, the public will not support changes to the health care system unless the essence of medicare is preserved. We see and hear, however, the words of those who would have us believe that the health care system is in crisis because of reduced government funding, and that the only way to keep the system running is to spend more money on it. It is time for other words to be heard, from other interests, so that all of us can become active and informed participants in the debate and make well-informed decisions that are consistent with our values.
Straight Talk About Health Care Reform
Medicare was not born overnight. Nor was it the outcome of calm, reasoned discussions. Its history is fraught with false starts, difficult and sometimes acrimonious federal/provincial relations, and numerous confrontations between governments and health care providers and suppliers. It is not surprising that health care reform has proven to be a daunting task in Canada.
But it is not just happening in Canada. Health care reform is a worldwide phenomenon. Governments everywhere are rethinking how their systems are organized, how many health care providers are necessary, how they should be paid and for what, how many hospital beds are necessary, how much governments should be paying for drugs, and, generally, how their systems can be reorganized to provide care more efficiently and effectively. Some countries have been more successful than others, but we have found no single recipe for success.
Fiscal restraint during the late 1980s and early 1990s has made change unavoidable, but we knew a long time ago that change was very desirable.
Many health reforms introduced in Canada over the last few years - and many more yet to be made - were advocated by a series of provincial Royal Commissions and task forces during the 1980s. The findings of these commissions and task forces centred on the notion that the system as a whole was fundamentally sound and adequately funded but could be improved. We believe that this holds true today.
- We believe that the health care system is fundamentally sound. First dollar coverage (i.e. no user fees) for "medically necessary" services fina nced through general taxation gives the best of two worlds. First, it ensures that Canadians will receive medical attention when they need it, not only when they can pay for it. Second, having twelve interlocking, single-payer health insurance plans (as opposed to many more privately funded plans) reduces administrative costs, promotes cost reduction rather than the shifting of costs from governments to individuals, and provides more consistency and bargaining power in dealing with health care providers and the health care industry. The profit motive in financing health care is both inconsistent with a view of health as a public good and moreover leads to high administration costs and inequities in access and quality. International evidence suggests that public funding and administration are the best ways to achieve fairness and value for money.
- We believe that in Canada we spend enough money on health care. The Forum's perspective is that we must look at the total amount being spent, including both public and private health expenditures. At roughly $72 billion annually, or $2,500 per capita, Canada has one of the most expensive health care systems in the industrialized world. One can argue about the relative shares of private and public funding or about the share of expenditures directed to physicians, hospitals or drugs, but we have no doubt that, at just under 10 percent of gross domestic product, Canadians are spending enough through their taxes and private payments to support access to needed health care.
- We believe the health care system can be improved. There is ample evidence that resources could be used more effectively and efficiently. For example, significant, unexplained variations in rates of surgical procedures are observed across the country; practice patterns change very slowly in response to evidence about the effectiveness of interventions; a large proportion of hospital days continue to be used by people who do not require acute care; inappropriate use of drugs is widespread - the list goes on.
If we were building a health care system today from scratch, it would be structured much differently from the one we now have and might be less expensive. The system would rely less on hospitals and doctors and would provide a broader range of community-based services, delivered by multidisciplinary teams with a much stronger emphasis on prevention. We would also have much better information linking interventions and health outcomes. However, because we are not starting with a blank slate, we must be careful about the pace of change so that both the public and the health care providers maintain their confidence in the system - a difficult balancing act. There is a limit to people's ability to cope with change. But being careful about the pace of change should not serve as an excuse to delay change unnecessarily.
We are convinced it is possible to maintain the health care system's basic principles throughout this period of change. While further efficiencies may be possible in a less rigid and compartmentalized system, the present structure cannot accommodate speedy and drastic reductions in funding without compromising something. We believe universal access is particularly vulnerable. Canadians value equitable access, and they value high quality services. If they sense that high quality service and universal health care are somehow not jointly achievable, they may withdraw their support for universal access. Should universal access be compromised, the game is over - medicare as we know it will be gone. It does not have to come to that! Equitable access and high quality care are achievable, provided certain changes are made.
Provincial and territorial governments are the best judges of the rate of change, since they are accountable for health care delivery and bear the consequences of their decisions most directly. Predictable, stable federal transfers are important in this regard. The federal government must refrain from imposing further change at a pace that cannot be absorbed by the provincial and territorial systems. That is why we recommended in early 1996 that a cash floor be determined for the Canada Health and Social Transfer. We suggested that it be established at the 1997-98 level of $12.5 billion. In providing this advice, we were conscious of the fact that there is indeed no magic number. We also recognized that the total federal transfer for social programs and post-secondary education is currently $25.1 billion, and includes both the tax points that were transferred by the federal government to the provinces, as well as the cash component.
The bottom line is that change is desirable and necessary to improve the health care system's responsiveness to the needs of Canadians. Simply doing more of what we ve been doing with fewer resources will not solve the problem. Part of the challenge lies in how we define the health care system. Currently, governments really manage only the "public" portion of the system - more than $52 billion worth of expenditure on hospitals, physicians, community health services, long-term care and a limited range of additional services. The remaining $20 billion, the "private" portion, pays for such services as drugs, other health professionals, and upgraded hospital accommodation, through private insurance or directly from the pocket of individuals. When public funding is reduced, the system typically responds by offloading costs to others or doing less, instead of doing things differently. But it is all the public's money, one way or another. If we focus on total costs and value for money, the evidence suggests that increasing the scope of public expenditure may be the key to reducing total costs.
The other part of the challenge relates to how health services are organized and delivered. Over the past three decades, technological and therapeutic enhancements have made it possible to shift away from an emphasis on hospitals and physicians and move towards a focus on non-institutional care, a broader array of health service providers, and greater reliance on home care and other forms of community-based care. However, the insular structure of the system has remained essentially intact, making it more difficult to respond to a rapidly changing environment. This has made it harder to coordinate health care services across settings and has aroused public concern that the "system" might not be there when people need it.
We conclude that Canadians want to preserve the fundamental principles of medicare. We must, therefore, complete the job of building medicare. We see maintaining - and expanding where appropriate - the role of public funding for health care as the key to successful restructuring. We see a need to reorganize the system to ensure that medically necessary care is funded regardless of where it is delivered or by whom. It makes little sense to guarantee public coverage when services are provided in hospitals, yet provide partial or no coverage at all for the same services out of hospital.
Restructuring means fundamentally reorganizing the system and changing the distribution of work. It does not mean simply doing more with less. It means integrating the funding and delivery of health care services through primary care reform and other organizational reforms. It also means reviewing the activities of all health care providers and taking down barriers that prevent the best use of the system's human resources. The status quo is a dead end we can ill afford. Neither can we succumb to the temptation of offloading public costs onto private budgets, either by arbitrarily deinsuring services or by implementing user fees in any form for medically necessary services. These "quick fix" solutions only undermine public support for the system and inflate total expenditures, while leaving the more fundamental issue of system structure unresolved.
The Bigger Picture of Health - What Really Matters
A true commitment to improving the health of Canadians involves more than reorganization of the health care system; it also involves action on factors outside the health care system that affect the health of the population. This recognition does nothing to diminish the importance of ensuring that people who are ill have access to care. Indeed, thoughtful and visionary discourse about the large picture of health will be unproductive if Canadians perceive it as a smokescreen to conceal an attack on access to health care services.
Although there are links between illness and health at an individual level, society's method for mobilizing resources to prevent and treat illness in individuals - the health care system - is not well suited to promoting health in the population as a whole. Since the release of the highly acclaimed Lalonde report, A New Perspective on the Health of Canadians in 1974, followed by Achieving Health for All (Epp) and the Ottawa Charter for Health Promot ion in 1986, we have broadened our understanding of the factors that contribute to better health and have taken action on a number of fronts. Initially, the focus of government policies was on lifestyle choices (diet, exercise, smoking) and on healthy public policy (e.g., seat-belt legislation). More recently, in large part because of research on the non-medical determinants of health and on health promotion, the focus has shifted to the societal level, beyond factors that are within the immediate control of individuals, professionals, and communities.
We believe that the social and economic determinants of health merit particular attention. This is not to diminish in any way the important contribution made by the promotion of healthy lifestyles or to downplay the role of other non-medical determinants of health, such as the physical environment and genetics. Rather, our goal is to raise awareness of the far reaching implications of social and economic factors and to propose concrete actions to improve the health prospects of Canadians.
We have known for some time that the better off people are in terms of income, social status, social networks, sense of control over their lives, self-esteem and education, the healthier they are likely to be. The wealthiest Canadians can expect to live four years longer than the poorest Canadians, and non-Aboriginal Canadians can expect to live seven years longer than Aboriginal Canadians. The difference between extremes - the rich and the poor, the advantaged and the disadvantaged - is not the only issue, however. We know that there is a gradient in health status, with health improving at each step up the slope of income, education and social status. We are all affected. Higher incomes are related to better health not only because wealthier people can buy adequate food, clothing, shelter and other necessities, but also because wealthier people have more choices and control over decisions in their lives. This sense of being in control is intrinsic to good health.
More recently, we have learned a great deal more about this relationship between health and social status. We are starting to understand how social determinants affect the body through biological pathways. For example, we know that the period from birth to the age of six in a child's life is critical because this is when the brain develops. Healthy brain development affects health and the capacity to participate fully as a citizen and productive member of society later in life. We also have witnessed how large scale social change can have a profound impact on health status. Japan is a good example of how a country can recover from the devastation of war to become one of the most prosperous and healthy of nations. In contrast, the decline in health status in eastern Europe since 1989 is a powerful reminder of the consequences of economic and social deterioration. While Canada is a long way from the situation of eastern Europe, we are concerned that unless we take action on the social and economic determinants of health, we could be facing potential stagnation or reversal of health gains.
We are particularly concerned about the impact of poverty, unemployment, and cuts in social supports on the health of individuals, groups and communities:
- Evidence suggests that deprivation during early childhood can impair brain development and permanently hinder the development of cognition and speech. The impact on children's physical and mental health is significant and can only be partially offset by interventions later in life. The environment in which children are raised affects not only the number of brain cells and connections but also how they are "wired" which, in turn, influences competence and coping skills.
- Unemployment has far reaching and extremely damaging effects on health for many individuals. The stresses and strains that accompany job loss erode an individual's physical and mental health and have significant repercussions on the health of other family members. Research also shows that recovery of health after re-employment is neither immediate nor complete.
- Changes in the labour market and cuts in social supports affect men and women differently. High rates of poverty among women who head lone parent households and among elderly women, as well as the increased burden of becoming caregivers that falls disproportionately on women, have adverse effects on women's health.
- The health of Aboriginal people continues to be significantly at risk. Unemployment rates, lack of education and welfare dependency are higher in First Nations communities, as is the incidence of violence, abuse and suicide. Aboriginal people are increasingly affected by conditions such as cancer and heart disease. The pandemic of diabetes and the vulnerability of Aboriginal children require immediate attention.
- The health of communities is stressed by the major socioeconomic changes experienced by their members. The level of social capital - i.e., the capacity and willingness of people to engage in collective, civic activities - in communities influences the degree to which they can respond to challenges such as poverty and unemployment.
There are success stories in Canada that demonstrate how individuals, communities and regions can overcome adversity and improve health through a variety of non-medical interventions. However, government does set economic and social policies that have important consequences for the health of individuals and populations. A better balance must be struck between short-term economic imperatives and the long-term health and well-being of Canadians.
Gaps and Underuse of Evidence in Decision Making
The ultimate goal of everything we do in the health sector is the improvement in health status and quality of life at the level of both populations and individuals. The acid test is whether services, programs and policies have improved health beyond what could have been achieved by doing something else with the same resources or by doing nothing at all.
Decisions about health and health care are made every day by patients, health care providers, managers, administrators and policy makers. In some cases, the evidence is clear cut and decisions are straightforward; in other cases, evidence is only one of many factors that must be taken into account. Decisions are influenced by the values and interests of decision makers, as well as the situation or context in which the decision is being made. Applying the best available evidence in the decision making process does not guarantee good decisions or outcomes, but it does improve the odds of achieving both.
The nature and quality of the evidence used also varies considerably. Not all interventions have been or can be subjected to the rigorous scrutiny of a randomized clinical trial. Knowledge also derives from qualitative research, imperfectly controlled studies, best practices, case studies, and of course, expert opinion. Where high quality evidence is lacking, experience, anecdotes, hypotheses or "gut reaction" have masqueraded as evidence. Myths and misinformation often camouflage, substitute for and sabotage the use of high quality evidence in decision making.
Unfortunately, high quality evidence is not always available for decision making, especially when new concepts are involved. We know that health is the result of the interaction of a number of factors, many of them non-medical and conditioned by genetic endowment and biological responses of the individual. We collect considerable administrative data about encounters in the health care system but insufficient data on results. Administrative data is rarely linked to information about the non-medical determinants of health, such as socioeconomic, employment and educational status, or to the outcome of specific interventions in these areas. There is little information resulting from analysis and translation of such linked data at either the individual or the population level. Tools, guidelines or care management strategies to assist in daily decision making have yet to be fully developed.
The National Task Force on Health Information (1991) presented comprehensive goals and a clear vision for a nationwide health information system. The Task Force identified several functions needed to ensure public accountability: collecting and analyzing information, reporting to the public on health status and health system performance, promoting the need for population health research and evidence-based decision making, and developing and responding to health policy. The Task Force also acknowledged that the development of a nationwide health information system requires cooperation and partnerships. In response to the Task Force recommendations, the Canadian Institute for Health Information was created to undertake the development and maintenance of a comprehensive and integrated health information system for Canada .
While many of the goals of the Task Force have been met, some have not. There is, therefore, a significant gap. Specifically, some of the many functions needed to ensure public accountability are not being fulfilled. As currently constituted, no organization has the capacity to carry out all of these functions. During the current wave of health restructuring, calls have increased for better information, not only to assist in making decisions about allocation of scarce resources, but also to monitor the impact of decisions already taken. The need for this information is all the more imperative in view of the current trend by provinces to decentralize health services at the regional level. We believe it is in the interest of all Canadians, regardless of where they live, that systems are in place to standardize and pool data at the national level. Otherwise, a community health centre in Saskatchewan will not be able to learn from the experience of a Centre local de services communautaires (CLSC) in Montreal (and vice versa). There is also an urgent need to identify and address gaps in our knowledge so that decisions can be based on appropriate, balanced and complete information on what works best. There appear to be significant gaps in the knowledge about women's health, ethnic and cultural influences, non-medical determinants of health, and alternative or complementary practices and therapies:
- In health and health care, gender counts. However, little is known about why the determinants of health appear to affect women and men differently. Further, there are not enough female researchers to promote women's health, nor are there enough women enrolled in clinical trials and other research initiatives to define risks and benefits of interventions, technologies and drug therapies for women.
- While there is evidence indicating that the health status of Aboriginal people is poor in comparison to that of the general Canadian population, information is lacking on effective, culturally appropriate interventions to improve the health status of Aboriginal people.
- The safety and effectiveness of alternative and complementary interventions also require urgent attention. Currently, we have little systematic information to help us determine which interventions are beneficial and which are potentially harmful. With the growing public interest in alternative therapies and treatment choices, it is imperative that assessment and evaluation be undertaken.
- Basic and clinical research continues to receive far more emphasis and funding than research on the non-medical determinants of health. This would appear to be a serious imbalance given the enormous impact of non-medical factors on the health of both individuals and populations. Knowledge about cultural and gender determinants of health is still very limited.
Decision-makers will use evidence only if it is clear, timely, and relevant to the issues and options under consideration. In addition, there have to be incentives to promote and reward the use of high quality evidence by decision-makers at all levels. Among other things, decision-makers, as opposed to researchers, need reliable, critical analyses and systematic reviews of often mountainous and complex evidence to inform their deliberations. The presentation of evidence to various decision-making audiences is an art in itself, and the failure to refine it will virtually guarantee that a great deal of excellent work will go unused.
The Forum is concerned about the asymmetry between the information available to health care providers and that available to patients. Traditionally, health care providers have been the main source of information and advice for patients. While this is still largely true today, we have heard of instances where patients using the Internet purport to know more about their conditions than their physician. The demand by patients for greater involvement in decision-making has made it essential that the public be able to access user friendly information. It also suggests that the role of health care providers will evolve toward a greater focus on interpreting information.
There is also a need to balance the privacy of individuals health information with the information requirements of practioners, decision-makers and researchers. Information about individuals is one of the key ingredients of a comprehensive health information system. Doctors and their patients benefit from access to complete patient records, which currently may be deposited in several locations. In emergencies, access to information about patients problems and treatment regimens may save lives. Access to health information and administrative data by health researchers can also benefit society. For example, access to employment data and links to health data would allow researchers to investigate the health effects of unemployment; access to the demographic statistics of patients can lead to a better understanding of specific health problems across the nation and to targeted, more effective health interventions.
In summary, our assessment of the current environment is that Canadians are very concerned about health and health care issues.
- Values, interests and opinions all have a bearing on future directions, but they must be carefully weighed to determine what is, from a long-term perspective, in the best public interest.
- The answer to the genuine need and desirability of health care reform will not be found in increased spending on health care.
- At the same time, emerging knowledge about health enhancing non-medical interventions demands action at all levels of society.
- There is a clear need for a greater focus on evidence-based decision making which will improve public accountability.
With a greater knowledge and understanding of the issues, coupled with a clear sense of the direction of change coming from governments, we are confident that Canadians will embrace change.
Priorities for Action
During our consultations, both the public and those involved with health and health care told us they will support change to the system, but they want a clear sense of the direction for the change. From our work, we have concluded that change is required in three key areas:
- preserving our health care system by doing things differently;
- transforming our knowledge about health into action;
- and using better evidence to make better decisions.
We propose a health care system that is built on the key features of our current system and on the values that underlie it. We see a system in which services are integrated and in which the care, not the provider or the site, is funded. To improve health status, we foresee action on the social and economic determinants of health - and in particular, making investments in children, lending support for community action, and placing a priority on the serious problem of unemployment. We propose a culture in which individual and collective decisions about health and health care are made on the best available evidence.
In "Setting the Context" we summarized our understanding of the issues, the tensions and the challenges in the field of health and health care. An in-depth analysis and a number of detailed recommendations are contained in the companion volume to this report. Here, we present our priorities for action.
1. Preserving Our Health Care System by Doing Things Differently
Knowing what to preserve and what to change are both key to improving our health care system. What must be preserved are the features of the system that ensure that high quality health care services are available to all who need them, at an affordable cost to society. What must change is the organization of the system; it needs to be more responsive, flexible and comprehensive.
The Forum recommends the following as the key features that must be preserved and protected:
- public funding for medically necessary services;
- the "single payer" model;
- the five principles of the Canada Health Act; and
- a strong federal/provincial/territorial partnership.
Preserving medicare, however, also means adapting to new realities by:
- expanding publicly funded services to include all medically necessary services and, in the first instance, home care and drugs; and
- reforming primary care funding, organization and delivery.
To support evidence-based innovations, we recommend:
- establishing a multi-year transition fund.
1.1 Preserving and Protecting Medicare
The Forum believes that the following are fundamental to preserving and protecting medicare:
- Ensuring full public funding for medically necessary services- This is consistent with a view of health care as a public good that should be provided on the basis of need and funded collectively through the tax system.
- Maintaining a "single payer" model at the provincial/territorial level - Mandating government to act as the funder of health services minimizes administrative costs and promotes cost control.
- Supporting the five principles of the Canada Health Act: universality, accessibility, comprehensiveness, portability and public administration - We believe that the Act is critical to preserving medicare, yet flexible enough to accommodate organizational reforms. It should not be opened.
Maintenance of these key features depends on a continued and strengthened federal/provincial/territorial partnership. Consistent with the strongly held views that emerged from our consultations with Canadians, we believe that the federal role in preserving and protecting medicare is important and must be maintained. This requires a significant and ongoing financial contribution through federal transfers. Federal transfers must be stable and predictable over time so that the pace of reforms at the provincial and territorial level does not become destabilized. In addition, we conclude that the federal government should not act unilaterally in other areas of federal policy in a way that would offload costs on provincial and territorial health budgets. We also recommend a much more collaborative approach to federal/provincial/territorial relations on health and health care of Canadians. This does not mean, however, joint federal/provincial/ territorial enforcement of the Canada Health Act, but it could mean a more transparent and open process. We strongly support the federal government's commitment to preserve the Canada Health Act and the actions it has taken to ensure that the Act is respected.
1.2 Building a More Integrated System
We have identified three areas for action to move toward a more integrated system that funds the care, not the provider or the site.
1.2.1 Home Care
Home care enables individuals with major or more minor limitations to live at home or in supportive housing. Home care services can assist in preventing, delaying, or substituting for long-term care or acute care alternatives. Such services include professional services, medical supplies, homemaking and attendant care, and maintenance and preventive care.
We believe home care should be considered an integral part of publicly funded health services.
- Provinces and territories should put in place a proper combination of insured services and other mechanisms to meet the needs of post acute, chronic care, and palliative care patients and those who, without maintenance and preventive care, would be at risk for reduced quality of life and subsequent institutionalization.
- Incentives should be geared to ensuring that people are treated in the most appropriate, cost effective setting, taking into account total public and private costs. Due regard should be paid to the burden on caregivers, many of whom are women, and often elderly women.
- A public, single point of entry, as exists in many provinces, should be used to conduct comprehensive multidisciplinary assessments to determine which services are needed on a case by case basis and to match these services with public and/or private providers.
Because pharmaceuticals are medically necessary and public financing is the only reasonable way to promote universal access and to control costs, we believe Canada should take the necessary steps to include drugs as part of its publicly funded health care system. Implementation of pharmacare must be carefully planned and take into account the following:
- Timing - Because of the magnitude of drug expenditures, increasing the share of public funding will hinge on the availability of fiscal resources. This reality should not distract from the central point: the issue is accessibility to needed services, combined with recognition that total costs may decrease if government costs increase. In fact, Canadians are already spending this money.
- Technical issues - Systems and policies must be in place to manage utilization, ensure appropriate prescribing, and control costs. Also needed are comprehensive information systems and reimbursement systems, such as competitive bulk purchasing and reference based pricing.
- Transitional issues - The absorption of currently operating private plans by a public system may involve transfer of funding sources as well as administrative apparatus.
We therefore call on the federal, provincial, and territorial governments, health service providers, private payers (employers and unions) and consumers to chart a course leading to full public funding for medically necessary drugs.
1.2.3 Primary Care
Primary care is the care provided at the first level of contact with the health care system the point at which health services are mobilized and coordinated to promote health, prevent illness, care for common illness, and manage ongoing health problems.
Reform of primary care is high on the agenda for all provinces and territories. We recognize that there is no single model that will work in all circumstances. However, key elements should include the following:
- realignment of funding to patients, not services; and
- a remuneration method that is not based on the volume of services provided by physicians but promotes a continuum of preventive and treatment services and the use of multidisciplinary teams of providers.
Primary care reform need not increase costs. It is essential to evaluate different models properly and to disseminate the results widely. Regardless of which funding methods are chosen, there should be safeguards to ensure that high quality care continues to be provided to those whose conditions incur higher costs, e.g., those who have serious illnesses or chronic conditions.
1.2.4 Transition Fund
To support evidence-based innovation in the directions outlined above, the federal government should establish a multi-year transition fund with $50 million in annual funding to:
- fund pilot projects that have a sound evaluation and research component and finance the evaluation components of existing projects;
- disseminate the results; and
- promote the implementation of the best models, as determined by evaluations.
The Federal/Provincial/Territorial Conference of Deputy Ministers of Health would be the best forum for devising a collaborative mechanism to administer the transition fund. Initiatives in Aboriginal communities should be considered a priority.
1.3 Financing Our Recommendations
Implementing our recommendations on home care, we believe, will not lead to a net increase in cost and should be funded by reallocation of savings from reductions in the institutional sector.
We believe that implementing our recommendations on pharmaceuticals will, in the long run, result in a net decrease in total drug costs for Canadians. There will be a requirement for an up front investment in information systems and information technology. To finance pharmacare, we are proposing a shift, over time, from private spending (by individuals directly or through private insurance for health benefits) to public spending, either through tax increases or premiums or both. The pace of implementation should be planned cooperatively by the federal, provincial and territorial governments; the federal role in financing must be worked out.
Primary care reform need not have additional costs. The health care transition fund requires additional federal expenditures of $50 million annually for a limited period.
2. Transforming Our Knowledge About Health into Action
Preserving universal access to health care and improving the efficiency and effectiveness of the health service delivery system are important public policy objectives. But improving the health of Canadians involves much more, because there is more to health than health care.
The Forum recommends that actions to improve the health of Canadians focus on the following elements:
- a broad, integrated child and family strategy consisting of both programs and income support (an integrated child benefit program; targeted, community-based programs with a home visiting component; better access to high quality child care and early childhood education services; workplace policies more favourable to families; and more equitable taxation of families with children);
- collaboration among the federal government, the private sector, and existing foundations to strengthen community action;
- an Aboriginal Health Institute to help Aboriginal communities find solutions to their health problems and take action; and
- explicit acknowledgement of the health and social impacts of economic policies, and action to help individuals who are trying to enter the workforce.
The Forum recommends significant investment in children and families. We recommend that the federal government, in cooperation with other levels of government, develop and implement a broad and integrated child and family strategy of programs and income support.
It is urgent to address the issue of poverty among children, especially Aboriginal children. We believe that the components of the strategy should be implemented in the following order of priority:
- An integrated child benefit program should be introduced to address the urgent problem of child poverty. This program should pay an income-tested benefit to low income families with children. The benefit, which should be implemented in cooperation with other levels of government, should replace the federal child tax benefit and provincial welfare payments on behalf of children, with a unified benefit for all low income families.
- Community-based programs with a home visiting component should be supported and strengthened where they exist and implemented where they do not, to help children develop resiliency and to foster the development of parental competence. Programs should be directed to pregnant women, and children from birth to 18 months, who are at risk. Particular attention should be given to the needs of Aboriginal women and children.
- Policies and programs should be reviewed and modified to ensure access to affordable, high quality child care and early childhood education services. Attention should be given to the needs of Aboriginal children. We believe that child care programs should be accessible to all, with parents paying fees on a sliding scale, based on ability to pay.
- Policies and programs in the workplace that support families through such measures as flexible hours, work sharing, extended maternity leave, paternity leave, day care or elder care, and unpaid leave should be developed. Governments, the health care sector, and the private sector should show leadership in this area.
- Taxation policies should be modified to create horizontal equity for families, by reducing taxes for those taxpayers with children, to reflect the costs of raising children.
Investing in Canada's children also means taking the necessary steps to protect them from key public health hazards. The long-term viability of the tobacco industry in Canada depends on a strategy of addicting children and adolescents, even in the face of irrefutable evidence that smoking kills. The Forum energetically supports the legislative and other measures taken recently by the federal government in this area.
2.2 Community Action
Society must recognize and support the role communities play in building social capital and positively influencing health. There is a need for a renewed partnership between communities, governments and the private sector; the following roles and responsibilities are suggested for each:
- Communities - The focus of control and management for community action must be at the local level. Communities are best placed to identify problems, assume leadership, and take action.
- Governments - Government funding continues to be an important resource for community action, but governments could greatly facilitate community access to public funds by breaking down the barriers among the various sectors of government activity.
- Private sector - The private sector has been spearheading pressure on governments to get their finances in order. The effects have been cutbacks in the social sector, including support to communities. Private sector sponsorship is an important resource for communities. We are calling on large and small businesses to become much more involved in community action by providing leadership in addition to money.
We recommend that the federal government work in partnership with the private sector and existing foundations (e.g. family foundations, Community Foundations of Canada and the Trillium Foundation) to create a national foundation to strengthen community action. The mandate of the foundation would be to reward and recognize communities for their leadership; stimulate the development of the required community leadership; and share best practices and information. Community action should help communities realize their goals by acting on the factors that determine health and should promote community integration, involvement, control and contribution.
A number of Aboriginal communities have taken action to address their problems. Aboriginal communities may be served better, however, by Aboriginal foundations bringing together the growing Aboriginal business community and existing foundations such as the Native Arts Foundation.
2.3 An Aboriginal Health Institute
Based on our own research and discussions with some Aboriginal people, we recommend the establishment of an Aboriginal Health Institute that would support Aboriginal communities in taking action to improve their health. The Institute would focus on Aboriginal health issues, including children's health issues, and serve a variety of functions:
- identifying approaches to disease management that are culturally relevant and appropriate for the context in which Aboriginal people live;
- performing and advocating health research to meet the needs of Aboriginal people and communities;
- sharing information within and outside Aboriginal communities;
- supporting Aboriginal health workers; and
- undertaking initiatives to increase advanced education for Aboriginal students in the health professions.
Economic policies, particularly those related to employment, have significant health and social impacts. Thus, we recommend:
- that all governments recognize that improving the health of the population depends above all on achieving the lowest possible unemployment rates;
- that priority be given to helping youth who are trying to enter the workforce and that barriers be reduced to make it less difficult for other groups to obtain employment, including people with disabilities, Aboriginal people and members of visible minorities;
- that all government economic policies (both fiscal and monetary) be analyzed explicitly from the perspective of their impact on health;
- that the proposed National Population Health Institute (see next section) report on the impact of economic policies, including the economic and social costs of unemployment, as part of their function of reporting on key public policy issues.
2.5 Financing Our Recommendations
While we recognize that implementing our recommendations concerning children would require significant additional funding, we have set them out in order of priority and believe that they can be implemented over time as fiscal circumstances permit. We are not recommending a particular amount for the integrated child benefit, nor have we calculated a total cost; there are others more qualified to do so. For example, the Caledon Institute of Social Policy has estimated the additional cost of an adequate benefit at $2 billion.
Programs aimed at children, including home visiting and access to high quality child care, will require additional funding. Programs with a home visiting component are currently supported by the federal government through the Community Action Program for Children and the Canada Prenatal Nutrition Program. We recommend that funding be maintained at 1996-97 levels and be used to strengthen the home visiting component of these programs. With respect to child care, a collective approach, led by the federal, provincial and territorial governments and involving major employers, is required to develop a strategy for this unmet social need.
There are a number of ways in which taxes can be reduced for taxpayers with children - tax credits and direct payments are two examples. We support the method that best fits the Canadian context and is the least costly to administer.
To support community action, gov ernments should maintain their current spending levels for local community development but must also coordinate their activities. The federal government should provide seed funding of $5 million for the national foundation, and the private sector should at the very least match this. Comparable funding should be provided for the companion initiative for Aboriginal communities.
We do not believe that funding the Aboriginal Health Institute will require new resources from government. Core support could be provided by redirecting current national level Health Canada expenditures. The Institute should seek support from, and partnerships with, research funders, non-governmental organizations, foundations and the private sector.
3. Using Better Evidence to Make Better Decisions
Individual and collective decisions about health, health care and the health care system have important consequences for us all. Improved decision-making processes will produce better decisions with better consequences.
The National Forum on Health has concluded that a key objective for the health sector should be to move rapidly toward the development of an evidence-based health system, in which decisions are made by health care providers, administrators, policy makers, patients and the public on the basis of appropriate, balanced and high quality evidence. In doing so, the potential role of information technology should be explored. The resources required to reach this objective should also be put in place. We recommend, on an urgent basis:
- that the federal Minister of Health take leadership in the development of an evidence-based system;
- that a nationwide population health information system be established to support clinical, policy and health services decision making, as well as decision making by patients and the public at large; and
- that a comprehensive research agenda be developed to address gaps in our current knowledge, and to identify mechanisms to promote analysis, translation, dissemination and uptake so that high quality content is available for the health information system.
The development of an evidence-based health system requires political will, leadership and champions.
We therefore call on the federal Minister of Health to champion the creation of an evidence-based health system, built on the foundation of a nationwide health information system. This active leadership role requires collaboration with both provincial and territorial health ministers and other federal departments.
3.2 A Nationwide Health Information System
We believe that the National Task Force on Health Information (1991) presented comprehensive goals and a strong vision for a nationwide health information system. While many of the Task Force goals have been met, some of the many functions needed to ensure public accountability are not being fulfilled. Therefore, we make the following recommendations:
- A national population health data network should be established, linking provincial and territorial agencies and a national agency. In creating this network, the Ministers of Health must ensure that issues (such as privacy, security and confidentiality), standards (technical as well as operational), and funding for research and development are addressed and that consensus on a national development and implementation plan is established.
- Provincial and territorial agencies should be mandated to develop and maintain a standardized set of longitudinal data on health status and health system performance and to advocate for, and advance, a population health agenda.
- A National Population Health Institute should be founded as soon as possible. Its mandate should be to aggregate and analyze data; develop data standards and common definitions; report to the public on national health status and health system performance; and act as a resource for the development and evaluation of public policy. The Institute would collaborate with provincial and territorial agencies. It would also report publicly on national trends, international and interprovincial comparisons, and key public policy issues.
- Governance and funding arrangements for the agencies in the network should be adequately balanced to preserve the agencies credibility and independence and be sufficiently secure over time to ensure their stability. The national agency structure should have provincial/territorial and academic involvement.
- For purposes of establishing the National Population Health Institute, there should be a review, without delay, of the mandates, organization and funding of existing agencies - particularly the Canadian Institute for Health Information (CIHI) - to ascertain whether any of them could fulfil the recommended mandate effectively. If not, a new agency must be created. Where applicable in provinces and territories, similar evaluations should be performed.
3.3 A Research Agenda for Health Information
The Forum recommends a comprehensive research agenda to advance the knowledge base and produce high quality content for the health information system. The following steps must be taken:
- A strategic overview of the current state of our health-related knowledge should be undertaken - what we know, what we don t know, and what we need to know to support the efficient and effective management of the health and health care sector. Gaps in our knowledge and areas where there is insufficient research, analysis and translation (e.g. the non-medical determinants of health; gender-specific health outcomes; women's health issues; Aboriginal health issues; and alternative and complementary practices) should be identified.
- The best mechanisms for promoting the analysis, synthesis, translation, dissemination and uptake of existing primary research data into useful knowledge should be identified.
- Requirements for human resource planning and development should be determined.
- Research funding should be shifted to create an appropriate balance between research on non-medical determinants and basic and clinical research. There should be an emphasis on career support funding and an appropriate balance between investigator initiated and policy relevant allotments. We recommend that an initial annual fund of $5 million of new resources be established and administered by the Social Sciences and Humanities Research Council. Priority should be given to research on the impact of key determinants of health, such as gender and culture, and to outcomes research, especially evaluation studies.
3.4 Financing Our Recommendations
Creating the population health data network will require government funding. If it is determined that CIHI is the appropriate national agency to carry out the mandate of the National Population Health Institute, its funding and operations will need to be revised to reflect this mandate. Whatever the organizational formula chosen to fulfil the goals, the cost of carrying out the required functions could be in the order of $15 million per year. In addition, government funds will be required for provincial and territorial centres. Based on current models, such centres require annual funding of $1-3 million, depending on the specific functions to be carried out. The combined funding requirements of all centres in the network could reach $25 million per year.
Filling the gaps in evidence will require funding for research. While we are not attaching an overall price tag to such research, government support, through existing research funding bodies and through the new Health Services Research fund, will be required. The federal government should allocate an additional initial $5 million annually to shift the funding emphasis towards a more appropriate balance between research on non-medical determinants of health, and basic and clinical research.
Mobilizing Our Resources to Move Forward
The Forum recognizes that the agenda we are proposing may appear ambitious - both in actions required and in financial investment. We are aware that this is a time when all governments are still trying to reduce their deficits and debt and that this battle is by no means yet won . Our recommendations require action now, but some actions can be taken in small steps, as fiscal circumstances permit. Implementing many of our recommendations would in fact entail a reshuffling of existing spending from one source to another. In other cases, we have recommended initiativ es that are costly, but we have done so only because the alternatives - doing nothing or doing too little - will in the end cost even more. Furthermore, when viewed in comparison to what Canadians spend privately or through their taxes on health care, our recommendations are not as costly as they might appear.
This ambitious agenda calls for action - but not only on the part of governments. Because the Forum was established by the federal government, we often wondered whether to restrict our advice to things the federal government could do. The more we heard from Canadians, the clearer it became that we would let them down if we did. For one thing, most people neither know nor care which level of government does what. If anything, they are tired of finger pointing and want everybody to get on with making things work. The "system", for its part, is made up of people who acknowledge their interdependency and are more than ready to cooperate. So we rejected the constraint of jurisdiction as a basis for formulating advice. We do identify some lead functions for specific groups so that action on our recommendations need not wait for someone to take the initiative. Taking the lead does not mean acting alone, however; in almost all areas, we are insisting on partnership and collaboration.
The federal government has a key role in supporting a national system of health care through federal legislation (the Canada Health Act) and stable, predictable transfers of money to provinces and territories. It must also protect the health of Canadians from threats such as infectious disease, unsafe food and drugs, and environmental pollutants. The federal government must take leadership in creating a culture of evidence-based decision making, through action on health information and knowledge generation. Implementing many of our recommendations - regarding children, employment, communities, and the integration of health services - will require partnerships with provincial and territorial governments.
Provincial and territorial governments, of course, control the organization and delivery of public health, health services, the activities of health professions, and labour relations with health workers. They also take political responsibility for health decisions and responsibility for the health effects of their policies governing the provincial/territorial economies and the physical and social environment. Clearly, most proposals for changes in health care require action from provincial and territorial governments. This does not eliminate the need for federal partnership and, where appropriate, financing. To the extent that regional health authorities have been given powers previously exercised by the provinces and territories, they too will be called upon to act on our recommendations.
Health service providers are often seen as both key enablers and inhibitors of change. There is no question that our recommendations will have an impact on the skills, numbers and mix of the health care workforce and its institutions. We look to the health professions to fundamentally change their approaches to education, research and care. We call upon professional associations, licensing bodies and educational institutions to work with governments, their members and the public to facilitate progress in the directions we recommend.
We have frequently identified the importance of both the volunteer sector and the business sector. Volunteers and their organizations contribute to community action, provide services in the community, and promote change in the interest of their members. The potential of the volunteer sector is especially great in community action. The business sector must renew its commitment to the life of the communities in which it operates. We believe that partnerships are stronger than solo initiatives and that the best partnerships bring public and business interests together. The research community will recognize that our work recommends a large research agenda in support of developing high quality evidence, disseminating the evidence that we do have, and evaluating the effect of using evidence in decision making. This applies as much to health and non-medical interventions as it does to health care and medical interventions.
The last word is for the people of Canada, who have both a right and an obligation to take charge of their personal health and to take part in health decisions made on their behalf. Not everyone can participate to the same extent, and obstacles are frequently encountered. Some of our recommendations are designed to lower the barriers and make more room for public involvement. We hope that such opportunities will be created and used to the maximum. Health and democracy are interdependent. One cannot be improved at the expense of the other.
We have inherited an excellent health care system developed over four decades. Let there be no question that this legacy is highly supported by people throughout the country. We also inherit tremendous health gains and advances in life expectancy made possible by economic and technological developments and by a relatively stable - by world standards - social and political environment. We cannot allow this legacy to be threatened. We believe this calls for careful and judicious new ways to invest our resources in society as well as in health care. Action now, is the key to preserve what we have acquired and to realize further gains in the future.
The National Forum on Health wishes to acknowledge our immense debt to the hundreds of people who met with us, sent us comments in briefs and letters, and shared with us their experiences. We also wish to express most sincere thanks to a dedicated Secretariat staff who provided professional expertise, energy and enthusiasm. Their contributions were vital to our work. A word of thanks also to the staff of the Minister of Health, Health Canada staff, representatives from the Prime Minister's Office, the Privy Council Office and to our provincial observers who participated and provided support and guidance throughout our deliberations. And a final word of thanks to all those who assisted with our consultations, communications and interpretation during the course of our work and travels.
Marie E. Fortier
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