Health, Education & Social Welfare

Canadian Federalism and Public Health Care: The Evolution of Federal-Provincial Relations

Jay Makarenko — Wed, 30 Jan 2008 11:15:18 -0700

One of the most critical issues in Canadian federalism since the 1950s has been the delivery of public health care. This article provides an introduction to the nature and evolution of federal and provincial relations in the area of health care policy, with particular focus on the fiscal and policy aspects and their impact. Included is a discussion of the basic division of powers in health care, Canadian federalism and the introduction of public health care, and shifts in this federal-provincial relationship since the 1950s.

Division of Powers and Health Care Policy in Canada

An overview of federal-provincial constitutional powers in the area of health care

Canadian Federalism and the Introduction of Public Health Care

Federal-provincial relations and the creation of the public health care system

Canadian Federalism and Public Health Care 1970-2000

Federal-provincial relations and public health care over three decades

Recent Trends in Canadian Federalism and Public Health Care

Shifts in federal-provincial relations in public health care between 1999 and 2004

Sources and Links to Further Information

List of article sources and links to more on this topic

Division of Powers and Health Care in Canada

An overview of federal-provincial constitutional powers in the area of health care

The Constitution, Federalism, and Health Care

The Canadian Constitution is the premier political institution in Canada. It sets out the basic structure and functions of government. Central to the Constitution is the establishment of a federal system in Canada, where there are two autonomous orders or levels of government: the federal (national) government and the provincial (regional) governments. The Constitution provides these different levels of government with their own constitutional powers and jurisdictions. As such, the Constitution, and its system of federalism, plays a central role in the context of health care policy; the Constitution established the role and powers of each level of government in creating and administering key elements of Canada’s health care system.

For more information on the Constitution and Federalism in Canada:

Mapleleafweb: The Canadian Constitution: Introduction to Canada’s Constitutional Framework

Provincial Powers in the Area of Health Care

Under the Constitution, the provincial level of government is granted the majority of legislative power in the area of health care. Section 92(7) of the Constitution Act, 1867 grants the provinces exclusive authority over the “establishment, maintenance, and management of hospitals, asylums, charities, and eleemosynary institutions in and for the province, other than marine hospitals” (Department of Justice Canada, Constitution Acts 1867 to 1982). In other words, only the provinces, not the federal government, may pass laws regarding the creation and administration of hospitals and mental health facilities.

Canada’s modern health care system, however, involves much more than simply the establishment and operation of hospitals. In response to this, the courts have interpreted the provincial power over hospitals in a very broad manner, extending provincial legislative authority to almost all areas of health care delivery. This includes areas such as health care insurance regulation, the distribution of prescription drugs, and the training, licencing and terms of employment for health care professionals, such as dentists, doctors, and nurses. This judicial interpretation has resulted in provincial dominance in the area of health care, at least with respect to the power to create laws concerning how health care is delivered to the majority of Canadians.

Federal Powers in the Area of Health Care

While the provinces enjoy the majority of legislative authority in health care, the federal government nevertheless has some important powers which enable it to play an important role in the development and implementation of health care policy.

First, the federal government is constitutionally empowered to legislate in select areas of health care, including marine hospitals, quarantines, and the oversight of food, pharmaceutical, and medical device safety. The federal government is also constitutionally responsible for health care delivery to certain groups in Canadian society that fall exclusively within the federal jurisdiction. This includes First Nations peoples living on reserves, the Inuit, serving members and eligible veterans of the Canadian Forces, members of the Royal Canadian Mounted Police (RCMP), inmates in federal penitentiaries, and refugee protection claimants.

Furthermore, the Peace, Order and Good Government section of the Constitution Act, 1867 (commonly referred to as the “POGG clause”)grants the federal government the power to legislate in areas outside its normal jurisdiction in times of national emergency. In the context of health care, this would include the power to legislate whenever health issues affect the nation as a whole or becomes a problem beyond a province’s ability to deal with it, such as in the event of a widespread epidemic. Under such circumstances, the federal government may assume control over health care delivery temporarily.

One of the federal government’s most important health-related powers, however, is its spending power. This refers to the constitutional right of a government to spend money in areas outside its normal constitutional jurisdiction. This spending power is available to both levels of government. It is, however, a much more powerful tool in the hands of the federal government, as Ottawa typically has a sufficient fiscal capacity to spend in its own areas of jurisdiction, as well as those of the provinces. Most provincial governments, by contrast, do not enjoy the same financial ability.

This spending power represents a key lever for the federal government as a means of exercising authority over the provinces and, indirectly, influencing health care policy. Each year, the federal government gives the provinces billions of dollars to support the delivery of provincial health services and programs. In so doing, the federal government regularly places conditions on the provinces in conjunction with this funding. It may require the provinces to spend the money on certain health services or programs, or to deliver health care according to specific federal standards and objectives. A province may, of course, refuse the federal funding and the conditions that come with it. However, most provinces are highly dependent upon Ottawa for health care funding dollars and simply cannot afford to forgo these funds.

Territories, Cities, and Health Care

Constitutionally speaking, neither territories nor cities have any powers in the area of health care. This is because neither is granted autonomy under the Canadian Constitution. Territories fall under the jurisdiction of the federal government and are creations of federal legislation; cities are under provincial jurisdiction and owe their existence to provincial legislation.

Even though the territories do not have any constitutional powers over health care, they nevertheless have control over the delivery of health care services for their own residents. This is because the federal government has provided territorial governments with powers and responsibilities similar to those held by the provinces (although, these powers are recognized only in federal legislation and not in the Constitution). Like their provincial counterparts, the territories oversee the creation and regulation of hospitals and other health-related facilities; distribution of prescription drugs; and the management of training, licencing, and terms of employment for health care professionals. While the federal government does not intervene directly in the health policy of the territories, it does exercise considerable influence through the financial transfer of funding, as it does with the provinces.

In the past, municipalities in Canada have played a large role in health care. Indeed, at one time, in some provinces, municipalities were charged with the responsibility for creating, funding, and administering hospitals. Since the introduction of public health care, however, the role of cities has been reduced considerably. Today, most hospitals are operated by provincial governments or health boards created and controlled by provincial governments. Nevertheless, some municipalities, especially in large urban cities, will deliver limited health services and programs, either independently or in cooperation with their respective provincial governments.

Canadian Federalism and the Introduction of Public Health Care

Federal-provincial relations and the creation of the public health care system

Early Health Care in Canada

Canada’s early health care system was drastically different than it is today. Prior to the 1940s, health care services were predominantly provided by private or charity hospitals and clinics. Canadians, generally, paid for their health care services, either directly, through charitable donations, or private forms of health insurance. Health care professionals, such as doctors, primarily operated as private businesses, either independently or in association with a particular hospital or clinic. There tended to be very little direct government involvement in health care delivery, although this did vary from province to province.

Introduction of Provincial Hospital Care Plans

Beginning in the late 1940s, Canadian health care began to take on aspects of its modern public form. In 1947, the Government of Saskatchewan, helmed by Premier Tommy Douglas, introduced the first universal hospital care plan. Under this plan, the provincial government assumed hospital-related costs for its residents. The government financed the plan through a combination of annual health premiums charged to residents and general provincial revenues. By 1949, Alberta and British Columbia had also introduced similar hospital care plans for their residents.

In 1957, the federal government became directly involved in public health care through passage of the Hospital Insurance and Diagnostic Services Act. This federal legislation committed the Government of Canada to financing 50 percent of the cost of provincial hospital care. In addition to providing federal funding for pre-existing plans in Saskatchewan, British Columbia, and Alberta, the federal government used the Act to negotiate publicly-funded hospital care plans in the remaining provinces. By 1961, agreements were in place with all provinces, providing hospital care coverage across Canada.

Introduction of Nationwide Medicare

The introduction of provincial hospital care plans meant that Canadians were covered for those medical services received within hospitals. This coverage, however, did not extend to the services of physicians received outside hospitals. The majority of Canadians, instead, were required to pay for these services, either directly, through private insurance schemes, or through non-universal public plans.

In 1962, the Government of Saskatchewan introduced universal coverage for physician services delivered outside of hospitals. Under the plan, physicians billed the government directly for the services they provided to their patients. Doctors, however, were free to practice outside the public system, and to charge higher fees than those reimbursed by the government (a practice called “extra billing”).

In 1966, the federal government introduced the Medical Care Act. Under this legislation, it committed to sharing costs with the provinces for all physician services, regardless of whether they were provided in a hospital. Moreover, the Act stipulated certain criteria which a province would have to meet in order to gain this federal funding.

The Act required that a province’s health plan be administered by a non-profit government agency (or some agency accountable to government); provide coverage for all medically necessary services rendered by a physician or surgeon; be universally available to all provincial residents on equal terms and conditions; and provide portability of benefits when the insured resident was temporarily outside of the province. Moreover, the Act stipulated that insured services were to be provided in a manner that did not preclude reasonable access to those services due to either direct or indirect charges. This limited the provinces’ discretion in charging health care premiums or to allow user fees and extra-billing by hospitals and doctors.

The federal government used the Medical Care Act as the basis for negotiating a nationwide public health care plan with the provinces (this nationwide system is commonly referred to as “Medicare”). By 1972, each province had established its own system of free access to medical services. While these provincial systems were framed by the basic conditions set out in the federal Act, there nevertheless existed significant differences from one province to another. Each province set up its own system of publicly administering hospitals. Moreover, there existed significant differences in terms of the services covered from province to province, as well as how each government paid for its public system. Some provinces, for example, introduced health premiums (annual payments made by individuals to the government to cover some of the costs of health care services). Other provinces paid for their public health plans exclusively through general tax revenues.

The introduction of national Medicare established the federal government as key player in health care policy. Under the Medical Care Act, the federal government committed to paying a significant portion of the costs associated with provincial Medicare plans (provided they met the criteria set out in the Act). During the period immediately following the introduction of Medicare, the federal government committed to paying one-half of whatever the provinces spent on health care coverage. Not only was the federal government a financial partner in public health care, but it was also able to indirectly influence provincial policy in this area through the conditions it attached to federal health funding under the Medical Care Act.

Federal-Provincial Inter-relationship in Public Health Care

Canada’s system of federalism had a significant influence on the manner in which public health care was instituted in Canada. Legislative authority for health care falls predominately within the hands of the provinces. As a result, Canada did not create a national health care system, at least in the sense of being centrally administered and completely uniform across the country. Instead, Canada’s public health care system is constituted by set of provincial regimes, which were instituted at different times and administered in different manners by their respective provincial governments.

Nevertheless, today, Canada’s public health care system can be considered ‘national’ in two important senses: a) through the use of its spending power, the federal government was able to encourage the implementation of some form of public health care across the entire country; b) as a financial partner in health care delivery, the federal government has been able to ensure basic criteria for the operation of these different provincial health care systems. While Canadians do not enjoy exactly the same public health care plans from coast to coast, provincial systems are uniform in terms of being publicly administered, relatively comprehensive, universal, portable, and without significant financial or other barriers to access.

Canadian Federalism and Public Health Care 1970-2000

Federal-provincial relations and public health care over three decades

The period between the 1950s and 1970s saw the federal and provincial governments put into place the basic framework for public health care in Canada. The decades that followed, however, saw increasing levels of tension and animosity between the two levels of government over public health care policy. This was due in large part to two main factors. The first were changes in federal funding to provincial health care plans, which saw the federal government withdraw from its earlier commitment to cover one-half of whatever the provinces spent. The second was the enforcement of federal criteria on how the provinces could operate their health plans.

Changes to Federal Health Care Funding

With the introduction of Medicare, the federal government committed to funding one-half of any provincial health care program which met the criteria set out in the Medical Care Act (see previous section). In the 1970s, however, the federal government became concerned over the rapidly escalating costs of social services, such as Medicare, and its ability to continue covering half of whatever the provinces spent.

As a result, in 1977, the federal government changed the nature of federal funding for public health care. It removed the detailed conditions placed on the provinces in order to receive federal monies. Provinces were no longer required to meet the criteria first established in the Medical Care Act. In return, the federal government announced that it would no longer pay one-half of the provincial program costs. It would, instead, only increase its funding to the provinces by a certain annual percentage – which would not necessarily cover one-half of the overall costs.

The 1980s and 1990s saw, again, a tightening of federal funding for health care, this time due to efforts by the federal government to control ballooning budget deficits. The most substantial development in the health care funding equation came in 1995, when the federal government introduced the Canada Health and Social Transfer (CHST). Previously, most federal funding for provincial social programs came in the form of Established Program Funding (for post-secondary education and health insurance) and a program called the Canada Assistance Plan (social assistance and welfare services). With the creation of the CHST, however, these federal transfers were merged into one block grant with few conditions on how the provinces spent the money.

Under the CHST, the Government of Canada reduced its overall financial transfers to the provinces. The CHST also altered the very nature of these transfers. Previously, many federal commitments, such as those dealing with provincial health care plans, were supported through cash payments to the provinces. Under the CHST, however, there was a greater reliance on tax point transfers for funding. Tax point transfers (better known as tax points) involve a reduction (or capping), by the federal government, of its taxation levels in order to provide additional ‘room’ for the provinces and territories. Accordingly, provincial/territorial governments are able to increase the amount of tax they charge to citizens and, in turn, raise new revenues to support their social programs.

These changes under the CHST had serious consequences for the provinces and their public health care systems. This was particularly true in have-not provinces – those that were highly dependent on federal cash transfers in order to pay for their health care plans. Not only were these provinces faced with reductions in overall federal transfers, but the shift to a greater reliance on tax points also posed challenges. With weaker tax bases, have-not provinces tended to benefit more from the transfer of dollars than from tax points. Consequently, many provinces faced a fiscal crunch due to rising health care costs and a reduction in the federal contribution to help offset those costs.

The result of these changes to federal funding: the provinces and territories were required to bear a greater share of the costs for social programs, such as Medicare. This resulted in a high level of animosity between the two levels of government, with the provinces regularly arguing that the federal government was not contributing its fair share to Canada’s public health care system.

Introduction of the Canada Health Act, 1984

Another important development to occur during this period was the introduction of the Canada Health Act in 1984. Originally, the federal government regulated the basic framework of provincial health care plans through the criteria outlined in the Medical Care Act. Following its 1977 decision to stop paying for one-half of health care costs, however, the federal government announced it would no longer place any conditions on federal funding in support of health care. As such, the provinces were free to administer their health care plans as they deemed fit.

This led to the introduction of a number of controversial measures by some provinces during the late 1970s and early 1980s, particularly user fees and extra-billing. User fees refer to the charges a patient is billed for specific medical services, such as a hospital visit; extra-billing (or double-billing) involves a practice where doctors charge patients fees for services in addition to seeking reimbursement for the provision of those services from the provincial government.

In response, the federal government introduced the Canada Health Act in 1984. The legislation re-established conditions that the provinces would have to follow in order to receive federal health care funds. Central to the Act was the prohibition of user fees and extra-billing, and the establishment of five basic criteria deemed essential for the operation of provincial health care services. These criteria closely matched those first introduced under the 1966 Medical Care Act, and required provincial plans be: publicly administered (administered by a public agency); comprehensive (cover all medically necessary services); universal (cover all provincial residents); portable (ensuring continued coverage when persons are temporarily outside of their home province); and accessible (reasonable access to health services without financial or other barriers).

For more information on the Canada Health Act:

Mapleleafweb: The Canada Health Act: Provisions & Administration

Additionally, the Canada Health Act included a penalty regime, under which the federal government would hold back funding to those provinces that failed to meet any of the Act’s criteria. While not widely used, this penalty regime has been applied in several instances. Immediately following the Act’s introduction in 1984, the federal government announced it would be applying penalties to those provinces that permitted user fees and extra-billing (the federal government later released the money it had held back, but only once the provinces had eliminated these practices). In the 1990s, the federal government applied the penalties on several occasions, mostly when provinces permitted the application of user fees in private medical clinics.

From the perspective of the federal government, the introduction of the Canada Health Act was an important instrument to maintaining certain national standards in public health care. From the perspective of the provinces, however, the federal action was viewed as an encroachment on provincial authority and jurisdiction. This concern was magnified, moreover, by the fact that the federal government had significantly, and unilaterally, reduced its financial commitment to provincial public health care plans.

Recent Trends in Canadian Federalism and Public Health Care

Shifts in federal-provincial relations and public health care between 1999 and 2004

Towards the end of the 1990s, tensions between the federal and provincial governments in the area of public health care were high. Yet another shift in the nature of federal-provincial relations would take place – influenced largely by the fact that the federal government had restored order to its fiscal house, bringing its budget deficits under control, and posting larger and larger annual surpluses. Moreover, the federal government showed signs it was willing to constrain use of its spending powers in areas of provincial jurisdiction, and work with the provinces to address health care-related issues.

1999 Social Union Framework Agreement

The first significant change came in 1999, when the federal government, provinces (except Quebec), and territories signed the Social Union Framework Agreement (SUFA). SUFA provides a framework through which the two levels of government can collaborate on Canada-wide priorities and objectives in the area of social programs.

For more information on the Social Union Framework:

Government of Canada: Social Union

Central to this framework were several key commitments by both levels of government. The provinces and territories agreed to eliminate residency-based policies that constrained access to social programs for migrants, and to use funds transferred from the federal government for agreed-upon purposes – which included health care policy. In return, the federal government agreed to limit the use of its spending powers by, for example, consulting with provincial and territorial governments prior to renewing or altering existing social transfers; not introducing new social programs funded through intergovernmental transfers without the agreement of a majority of provincial governments; and providing prior notification before introducing new Canada-wide social programs funded through direct transfers to individuals. The first two of these commitments are highly relevant to health care, as they require that the federal government work with the provinces and territories before making significant changes to the basic funding or framework of the public health care system.

In addition to its commitments under SUFA, the Government of Canada also announced a multi-billion dollar increase in transfers to the provinces in the 1999 federal budget. This increase was intended to alleviate some of the financial burden on the provinces vis-à-vis the rising costs of social programs, including health care.

2002 Romanow Commission on Health Care

Another key development in this story on health care policy: the Royal Commission on the Future of Health Care, headed by former Saskatchewan premier Roy Romanow. Formed in 2001, the Commission’s mandate was to review federal, provincial, and territorial policies in health care and recommend possible measures for reform. The Commission’s final report, tabled in November 2002, comprised 47 detailed recommendations, touching on a wide range of health care-related issues. Central to the Commission’s report was the recommendation that Canada should continue to pursue a public health care system where the cost of medical services was covered by governments.

In the broader federalist context, the Commission recommended significant changes to federal-provincial/territorial relations within the realm of health care policy. Generally speaking, the Commission suggested a collaborative relationship between the levels of government – a relationship where each level of government was an equal partner in the public health care policy. Additionally, the Commission recommended enacting a Health Covenant which would have set out a national vision and framework for public health care, and be binding on all governments. It also recommended that a Health Council of Canada be created, with the goal of fostering collaboration between levels of government.

The Commission also recommended dramatic changes to federal financial support of provincial health care plans. This included creating a new federal transfer, which would solely target health care. (At the time, federal transfers for health care were lumped together with monies for other social programs under the Canadian Health and Social Transfer.) The Commission suggested this new transfer be cash-only, rather than consisting of a combination of cash and tax transfer points. Finally, the Commission recommended the federal government increase its share of federal funding for health care to a minimum of 25 percent of provincial/territorial costs. This represented an increase over existing federal funding levels at the time, but was still significantly lower than the 50 percent promised by the federal government when Medicare was first introduced.

Another Commission recommendation: the broadening of Canada’s public health care system to include uniform national coverage for prescription drugs. This included the introduction of provincial/territorial drug plans, which would be paid for, in part, by a new federal ‘Catastrophic Drug Transfer.’

For more information on the Romanow Commission:

Mapleleafweb: Romanow Commission on the Future of Health in Canada: Findings and Recommendations

2003 Accord on Health Care Renewal

While the Romanow Commission’s report was not binding on any of the governments, some of its recommendations were enacted through subsequent federal-provincial/territorial agreements on health care. The first of these was the Accord on Health Care Renewal, agreed to by all governments in 2003. The Accord constituted an action plan to improve timely access to quality health care for all Canadians. Under this plan, the federal government committed $34.8 billion dollars in additional funding for health care over the five-year period from 2003-04 to 2007-08. In 2004, the federal government added an additional $2 billion, bringing the total to $36.8 billion over the five-year period.

In addition to this increase in federal funding, the Accord also led to several other key initiatives. Under the Accord, governments created the Health Council to monitor and make public reports on the Accord’s implementation. The federal government also split the Canada Health and Social Transfer into two block grants: the Canada Health Transfer (CHT) and the Canada Social Transfer (CST). The objective in this division was to enhance transparency and accountability, both with respect to the amount of money transferred by the federal government for health care and how that money was spent by the provinces and territories.

As part of this Accord, the governments committed to ensuring Canadians would have reasonable access to catastrophic drug coverage by the end of 2005-06, with part of the $36.8 billion in new funding to be committed to new provincial drug plans. As of December 2007, however, little action had been taken on establishing national catastrophic drug coverage.

For more information on the 2003 Accord on Health Care Renewal:

Government of Canada: 2003 First Ministers’ Meeting on Health Care Renewal

2004 Agreement on the Future of Health Care

A year later, federal, provincial, and territorial governments agreed to a new 10-year plan to sustain the public health care system. Under the agreement, the federal government committed to provide an additional $18 billion to the provinces and territories over the next six years for health care. The federal government also guaranteed a 6 percent annual increase in federal health transfers after that until 2015. According to the federal government, this amounted to $41 billion in new funding over 10 years. This new money is in addition to the $36.8 billion agreed to in the 2003 Accord.

In return, the provinces (except Quebec) and territories agreed to a number of federal demands in the area of waiting times and home care services. This included setting common benchmarks for measuring waiting times across the country, and achieving agreed upon reductions in waiting times for medical treatment in five key areas (cardiac care, cancer treatment, diagnostic imaging procedures, joint replacement, and sight restoration). The provinces/territories also agreed, by 2006, to increase funding for certain home care services, such as short-term acute and mental health care, and for longer term end-of-life care.

In order to bring Quebec into the new health care arrangement, the federal government agreed to a separate agreement with the province, official entitled Asymmetrical Federalism that Respects Quebec’s Jurisdiction. Under this deal, Quebec promised to reform its home care services in its own way. The province also agreed to set its own benchmarks and indicators for waiting times that would be comparable to those implemented by the other provinces.

Another important element of the 2004 health care agreement was the establishment of a mechanism for resolving future disputes regarding the Canada Health Act. Originally part of the 1999 Social Union Framework Agreement and agreed to in a 2002 letter of intent, the purpose of the new mechanism was to minimize inter-governmental conflict over the interpretation and application of the Act’s basic criteria for provincial health care plans. In addition to a commitment by all governments to work together to avoid disputes before they occur, the new mechanism also included specific procedures for dispute resolution, most notably the establishment of a third-party panel to review disputes and make recommendations. It is important to note, however, that the decisions of the third party panel are not binding, meaning that the federal government retains final authority to apply the Canada Health Act.

For more information on the 2004 Health Care Agreement:

Government of Canada: First Minister’s Meeting on the Future of Health Care

Renewed Federal-Provincial Partnership in Health Care

The period between 1999 and 2004 saw a significant shift in federal-provincial relations in the area of health care. That said, the basic structure of federalism and public health care remains, with the provinces and territories responsible for administering their own public health care plans and the federal government acting as financial partner and enforcer of basic uniform, national standards. Nevertheless, the tone of the relationship between the two levels of government has changed from the highly combative situation of the 1970s, 80s, and 90s. This was due, in large part, to significant increases in federal funding for public health care – a critical demand for the provinces and territories. Moreover, through several agreements, including the Social Union Framework Agreement, the 2003 Accord on Health Care Renewal, and the 2004 Agreement on the Future of Health Care, the governments established key commitments and mechanisms for dealing with health priorities while minimizing inter-governmental conflict.

This, however, is not to suggest a complete absence of federal-provincial tension in health care. Continued rising costs and differences of opinion between governments on such issues as the Canada Health Act, waiting times, home care, and pharmaceutical coverage, will all continue to be potential sources of animosity between governments into the foreseeable future.

Sources and Links to Further Information

List of article sources and links for more on this topic

Sources Used for this Article

Dyck, R. Canadian Politics: Critical Approaches, 3rd Edition. Scarborough, Ontario: Nelson Thomson Learning., 2000.
Jackson, R. & Jackson, D. Politics in Canada: Culture, Institutions, Behaviour and Public Policy, 6th Edition. Toronto: Pearson Education Canada Inc., 2006.
Guest, D. The Emergence of Social Security in Canada: 3rd Edition. Vancouver: UBC Press., 1999.
Jackman, M. “Constitutional Jurisdiction Over Health in Canada.” Health Law Journal. 2000. 11 December 2007. <http://www.law.ualberta.ca/centres/hli/pdfs/hlj/v8/jackmanfrm.pdf>.
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Houston, S. “Hospital Services Plan.” The Encyclopedia of Saskatchewan. 11 December 2007. <http://esask.uregina.ca/entry/hospital_services_plan.html>
“1957 – Advent of Medicare in Canada: Establishing Public Medical Care Access.” Government of Canada. 11 December 2007. <http://www.canadianeconomy.gc.ca/english/economy/1957medicare.html>
“Canada’s Health Care System.” Health Canada. 07 June 2006. 11 December 2007. <http://www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/2005-hcs-sss/back-context_e.html#2>
“The 2003 Accord on Health Care Renewal: A Progress Report.” Health Canada. 09 May 2006. 11 December 2007. <http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/fs-if_01_e.html>
“First Ministers’ Meeting on the Future of Health Care 2004.” Health Canada. 09 May 2006. 11 December 2007. <http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/index_e.html>
“2006 Annual Report: Pharmaceutical Management.” Health Council of Canada. 11 December 2007. <http://www.healthcouncilcanada.ca/en/index.php?option=com_content&task=view&id=79&Itemid=80>

Links for Further Information

Child Care in Canada: An Introduction

Jay Makarenko — Mon, 17 Sep 2007 12:29:58 -0600

Child care is a significant issue in the context of Canadian public policy and the relationship between federal, provincial, and territorial governments. This article provides an introduction to the complex nature of child care policy, including the operation of child care vis-à-vis Canadian federalism, an overview of provincial/territorial child care policies, a historical review of federal and intergovernmental child care initiatives, and a brief discussion of key issues in the politics of child care.

Canadian Federalism and Child Care

Federal and provincial roles in child care

Provincial/Territorial Child Care Polices

Approaches to child care across provincial jurisdictions

Federal Government: Child Care Policies

Overview of child care policies at federal level

Intergovernmental Agreements on Child Care

Federal-provincial/territorial relations in child care

Issues in Canadian Child Care Policy

Basic debates in the politics of child care

Sources and Links to More Information

Lists of article sources and links to more on this topic

Canadian Federalism and Child Care

Operation of child care in Canada’s federal system

In examining child care policy in Canada, one issue that must be addressed is the role of different levels of government in this policy field. This provides important context in understanding the current operation of child care programs in Canada, as well as examining why the child care debate is often framed in the manner that it is.

Provincial Jurisdiction in Child Care

Under Canada’s Constitution, the authority to legislate in the area of child care falls under provincial jurisdiction. This includes the power to implement public child care programs, to permit or prohibit private child care providers, to regulate what sorts of services child care facilities are to provide, and to dictate what sort of education and certification child care professionals must have to provide their services.

Provincial governments also have the constitutional power to provide financial benefits in the area of child care. This may include provincial tax credits (which parents may apply towards child care costs), as well as direct subsidies to child care providers to reduce the cost of child care for parents. The decision whether to subsidize child care or not, and to what extent, is completely up to the individual provincial government.

Federal Jurisdiction in Child Care

The federal government, by contrast, does not have the general constitutional authority to legislate in the area of child care. This means that it cannot pass laws or legislation pertaining to how child care programs operate or who is eligible to provide child care services. There are, however, some qualifications.

The federal government does have constitutional authority to legislate social services for particular groups in Canadian society, such as Aboriginal Peoples and members of the Armed Forces. In these cases, the federal government can unilaterally implement particular sorts of child care programs. In an Aboriginal context, for example, the federal government has implemented the Aboriginal Head Start program. It provides half-day preschool for young Aboriginal children, and focuses on elements such as school readiness, Aboriginal culture and language, and health promotion.

The federal government can also play an indirect role in child care policy through the use of its constitutional spending powers. While the Constitution disallows the federal government from directly regulating the operation of child care programs, it nevertheless permits the Government of Canada to spend federal monies in this area. The federal government can use this spending power to institute limited forms of child care initiatives. The federal government may, for example, provide financial subsidies to parents in support of child care – either in the form of direct payments or tax credits. It can also use its spending powers to influence provincial policies in child care. The federal government may, for example, commit federal funds to a province if that province institutes certain child care policies.

Fragmentation of Child Care Policy in Canada

An important characteristic of child care in Canada is the tendency towards fragmentation. Programs and initiatives differ, not only between groups, such as Aboriginal and non-Aboriginal Canadians, but also between regions, with individual provinces and territories pursuing alternative child care objectives and programs. At the national level, while there are federal and intergovernmental programs and strategies, such national initiatives tend to maintain provincial independence (and, in turn fragmentation) in child care policy rather than reducing it.

This situation can be viewed as either positive or negative, depending on one’s political orientation. For example, for those whom believe that provinces and territories should be free to pursue their own independent social policy, the fragmentation of child care policy would seem to be natural. For those whom believe that there should be a national and universal child care policies in Canada, this fragmentation could be viewed in a negative light.

Provincial/Territorial Approaches to Child Care

Approaches to child care across the provinces and territories

In Canada, child care is deemed to be an area of provincial responsibility. Accordingly, provincial governments hold different views as to what the state’s role in child care should be. There is, consequently, a great deal of variation in how child care is delivered from province to province across the country. The following section examines the similarities and differences in child care policies across the country.

Overview of Child Care Providers

In many cases, parents or extended family members provide child care. Outside of family members, the majority of child care in Canada is provided by private individuals or agencies, which offer child care services as a private business. In some cases, these are for-profit agencies, while in other cases they are not-for-profit child care providers. In each situation, however, parents are charged a fee in exchange for child care services received.

Only a small percentage of child care facilities in Canada are publicly operated, either by provincial or municipal governments. Most, instead, are owned and managed by private individuals, agencies, or businesses. Provincial/territorial governments do, however, provide a form of child care through their basic education systems – as is the case with kindergarten, which is available to children around the age of five or six. It is important to note, however, that provincial and territorial kindergarten programs are meant to prepare children for primary and secondary schooling, as opposed to being a “child care” service.

Provincial/Territorial Subsidies for Child Care

Most provinces and territories provide some form of financial subsidy in support of child care costs. The nature and extent of these subsidies, however, varies from jurisdiction to jurisdiction. Quebec offers the closest example of a publicly-funded child care system in Canada. There, the Government of Quebec initiated a network of community-based, not-for-profit child care centres; they are independently operated, but funded primarily by public monies (parents are charged a nominal daily fee to enroll their children in these child care centres). Other provinces and territories also subsidize child care facilities and services, although not to the same extent as in Quebec. In those provinces, parents are required to cover the majority of costs associated with child care.

Another form of provincial/territorial support for child care is direct subsidies to parents. These may come in the form of either direct payments to parents for child-based costs (including child care), or through provincial/territorial tax credits. In the case of the latter, parents claim the tax credits to reduce their annual tax liability, and then can use the savings to cover their child-based costs. These subsidies are usually completely discretionary, meaning that parents may use the funds in any way they wish, be it for child care or otherwise. Moreover, in some cases, these subsidies specifically target lower-income families, while in other cases they are provided universally to all parents.

For more on provincial/territorial subsidies to parents:

Canada Revenue Agency: Provincial and Territorial Programs

Provincial/Territorial Regulation of Child Care Services

Finally, all provinces have instituted some form of regulation of child care services, in particular those provided by child care professionals. This would include regulation of who is eligible to provide child care, as well as standards of child care services. Again, the precise nature and extent of these regulations differs from jurisdiction to jurisdiction.

Quebec has the most comprehensive system of child care regulation, due in large part to the highly public nature of the services it provides. The Quebec government regulates the governing structures of public child care facilities (requiring them to be community operated with the participation of parents), access to those child care facilities, the qualifications and pay of child care workers, as well as the standards of child care services. To the latter point, the Government of Quebec has adopted a broad early childhood development program which it institutes through public child care facilities.

For more information on the regulation of child care services in Quebec:

In the remainder of the country, regulation of child care services varies considerably. All provinces and territories require particular qualifications for child care workers, and certain standards of health and safety in the operation of child care facilities. Most jurisdictions also have some sort of early childhood development program, which they institute through their child care policies. However, the precise nature and extent of these programs varies significantly.

For more information on provincial/territorial regulation of child care services:

Federal Government Child Care Policies

Overview of federal child care-related programs

The federal government has instituted its own programs in the area of child-rearing and care. The following section provides an overview of these programs.

Maternity and Parental Benefits

One form of federal support for child care is maternity and parental benefits offered through the federal Employment Insurance Program (EI). These benefits are provided to birth or surrogate mothers, biological fathers, and adoptive parents, who have made payments into the EI Program for a certain period of time. Under federal EI, maternity or parental leave is considered to be a legitimate cause of absence from work, such as unemployment or sickness, and is thus eligible for payment of employment insurance benefits. Accordingly, a parent may take an absence from work in order to care for a child for certain period of time, during which they will receive monthly payments from the federal government. These payments are usually based upon the number of insured hours worked prior to the leave, and salary earned.

It is important to note that these benefits must be claimed shortly before or after the child’s birth, and are only paid for a fixed length of time (usually around one year in total). As such, EI maternity and parental benefits are only viable as a means of child care support in the very early stages of a child’s life.

For more information on federal EI maternity and parental benefits:

Government of Canada: Employment Insurance (EI)

Child-Based Tax Credits to Parents

In addition to maternity and parental benefits, the federal government also provides support for child care through child-based tax credits to parents.

The first federal child-based tax credit was the Child Tax Exemption, introduced in 1918. Under the Exemption, families with children were provided with tax credits that could be used to reduce annual federal tax obligations. These tax benefits were completely discretionary, meaning that parents could use the funds in any manner they saw fit, be it in support of child care or otherwise. This tax benefit remained in place until it was replaced in 1978 by the Child Tax Credit (see below).

In 1972, the federal government introduced the Child Care Expenses Deduction, which provided a tax deduction to families with child care expenses related to work. The Deduction was in addition to the Child Tax Exemption, and was only applied to families that were required to secure child care in order to earn a living. The Deduction was not available to families in which one parent stayed home to provide child care. Moreover, the Deduction only applied to families with older children, as opposed to those with an infant or toddler.

In 1978, the federal government replaced the Child Tax Exemption with the Child Tax Credit, a system of refundable and non-refundable tax credits. As with the previous Child Tax Exemption, the new child tax credit system was completely discretionary, meaning that parents could use the funds gained in any manner they chose, be it for child care or otherwise. The system was also structured in a manner to give preferential treatment to families with lower incomes. Those with lower household incomes received a larger tax credit than those with higher incomes. In some cases, parents whom earned a household income over a certain threshold were excluded from claiming the tax credit altogether. In 1992, the Child Tax Credit was rolled into the Child Tax Benefit, which was a payment-based system of federal child support (see below).

In 2007, the federal government re-introduced a tax credit for families with children. This tax credit is for children under the age of 18 and is based on the number of children in the family. The funds received from the tax credit are completely discretionary, meaning families may spend the funds in any way they like – be it on child care or not.

Child-based Payments to Parents

Another form of federal support in the area of child care is direct child-based payments to parents. The first of these programs was the Family Allowance Program (commonly referred to as the “Baby Bonus”), introduced in 1945. This program involved a monthly federal payment directly to families with children, with the purpose of increasing household spending power and ensuring the basic needs of children were met. Again, the Program was completely discretionary, meaning that parents could use the monthly payments however they saw fit – be it for child care or otherwise. Initially, the Program was applied universally to families with children under the age of 16, meaning that all eligible families received the same benefit regardless of their income level. Over time, the Program was extended to include families with children up to the age of 18 (where the child was attending school, or the child was disabled), and was evolved to target only those families with lower levels of income.

For more information on the Family Allowance Program:

In 1992, the federal government consolidated the Family Allowance Program and Child Tax Credit (see above) with a new Child Tax Benefit. Under the Benefit, parents received monthly federal payments based on the number of children in the family, as well as the level of household income. Those families with lower incomes received a larger benefit than those with higher incomes. Again, the Child Tax Benefit was a discretionary benefit, meaning that parents could use the funds in any manner they saw fit, be it in support of child care or otherwise. In addition to the Child Tax Benefit, the Government of Canada introduced the Working Income Supplement, which was provided to working poor families. The Supplement was intended to provide working families at low-income levels with additional resources for child-rearing costs, including child care support.

The federal government again modified its system of child-based payments to parents in 1998, with the introduction of the Canada Child Tax Benefit (which replaced the Child Tax Benefit). This new benefit system is a joint federal-provincial/territorial program, administered by the federal government. It provides monthly payments to families with children. The Canada Child Benefit also included a new National Child Benefit Supplement, oriented towards lower-income families; it replaced the previous Working Income Supplement. As was the case under previous systems, the Canada Child Tax Benefit and National Child Benefit are discretionary payments, meaning that parents may spend the funds as they see fit, be it on child care or otherwise.

For more information on the Canada Child Tax Benefit and the National Child Benefit:

Revenue Canada: Canada Child Tax Benefit (CCTB)

Finally, in 2006, the federal government implemented the Universal Child Care Benefit. This new benefit is a monthly federal payment to help families, with children under the age of six, provide child care. The Benefit operates in addition to the federal-provincial/territorial Canada Child Tax Benefit and National Child Benefit, as well as the federal Child Care Expenses Deduction (see above). Like the Canada Child Tax Benefit, the Universal Child Care Benefit is a discretionary payment; parents may use the funds for whatever purpose they wish.

For more information on the Universal Child Care Benefit:

Revenue Canada: Universal Child Care Benefit (UCCB)

Intergovernmental Agreements on Child Care

Federal-provincial/territorial relations in child care

While it is generally the case that federal, provincial, and territorial governments pursue their own programs in child care, there is some level of cooperation between levels of government. These involve federal-provincial/territorial funding arrangements for child-based benefits, as well as national agreements on child-based agendas.

CAP, CHST and Child Care

One of the key areas of federal-provincial/territorial relations in child care has been through federal funding arrangements for provincially-delivered child-based benefits and services. The first these initiatives came during World War II, with the increased need for women in the workforce. In 1942, the federal government established the Dominion-Provincial Wartime Agreement. Designed to encourage the provinces to provide care for the children of women working in essential wartime industries, this Agreement established that the federal government would pay 50 percent of the total cost associated with the provision of these services. Only two provinces, Quebec and Ontario, chose to participate in the short-lived program. The federal government subsequently withdrew its support at the end of World War II.

In 1966, the federal government again decided to wade into the field of child care, this time through the Canada Assistance Plan (CAP). Under the CAP, the federal government reimbursed the provinces for 50 percent of their eligible social service expenses, regardless of the total amount. The CAP included funds for child care, treating it as a welfare-type program.

Since its introduction, the CAP has undergone several key evolutions. In 1995, the federal government altered it by combining those fiscal transfers with federal funding for health care and education into a single ‘block’ transfer know as the Canada Health and Social Transfer (CHST). The federal government also significantly reduced its financial contributions under the CHST, requiring the provinces to cover a greater share of the cost of many social programs, including those related to child care. To compensate for these reductions in transfers under the CHST, the federal government granted the provinces greater flexibility in how they spent the funds. In the context of child care, the federal government removed the requirement for the provinces to spend money on child care programs in order to receive federal funds under the CHST.

Early Childhood Development Initiative

In 1999, Canada’s First Ministers (with the exception of Quebec Premier Lucien Bouchard) signed a framework agreement outlining a new relationship between the federal government and its provincial/territorial counterparts – a relationship which was formalized under the Social Union Framework Agreement. A cornerstone of the Social Union is the National Children’s Agenda (NCA). The NCA is a far-reaching policy document designed to establish a shared vision among the 14 governments (federal, provincial, and territorial) for enhancing the well-being of Canada’s children, as well as a common understanding of the changing circumstances and needs of children. The National Children’s Agenda also established that the provinces and territories are free to tailor agreed-upon policies and programs in a manner that best meets the needs of their respective jurisdictions.

The Early Childhood Development Initiative (ECDI) is one of the programs developed under the National Children’s Agenda. The ECDI targets four specific areas of early childhood development: promoting healthy pregnancy, birth, and infancy; improving parental care and family supports; strengthening early childhood development, learning, and care; and, strengthening community supports. In 2002, the federal government committed $2.2 billion in Early Childhood Development Initiative funding over a five-year period. This funding was delivered first through the Canada Health and Social Transfer, and then the Canada Social Transfer (after the federal government moved to split the CHST into two separate funds in 2004 – the Canada Health Transfer and the Canada Social Transfer).

A key component of the ECDI was the allocation of some funding to improve the quality of, and access to, child care across the country. The ECDI, however, did not clearly stipulate the amount of ECDI funds that the provinces and territories were to spend on child care, or the sort of child care programs that were to be pursued.

2003 Multilateral Framework on Early Learning and Child Care

In 2003, the federal, provincial, and territorial governments (with the exception of Quebec) agreed to the Multilateral Framework on Early Learning and Child Care. The primary objectives of this agreement is to promote early childhood development, and to support the participation of parents in employment or training by improving access to affordable, quality early learning and child care services.

Under the Framework, the federal government committed $1.05 billion in funding over five years. In exchange, the provinces and territories agreed to invest the federal funds in early learning and child care programs for children under the age of six. This included programs and services that provided direct care and early learning for children in settings such as child care centres, family child care homes, preschools, and nursery schools. Investments in programs and services that are part of the formal school system were not included. It is important to note that while the Government of Quebec did not agree to the Framework, it still received its federal funding share.

For more on the Multilateral Framework on Early Learning and Child Care:

Government of Canada: About the Federal/Provincial/Territorial Multilateral Framework on Early Learning and Child Care

Federal-Provincial/Territorial Bilateral Agreements on Child Care

In addition to the Early Childhood Development Initiative and the Multilateral Framework on Early Learning and Child Care, several bilateral agreements on child care were struck by the federal government and individual provinces and territories. The purposes of these bilateral agreements were to describe specific objectives and investments on early childhood learning and child care that were tailored to the particular needs and priorities of individual provinces and territories.

For more on the details of these bilateral agreements:

2006 Child Care Spaces Initiative

In 2006, the new Conservative federal government significantly altered federal-provincial/territorial relations in child care with the introduction of the Universal Child Care Plan. Under this Plan, the federal government unilaterally revoked all previous bilateral agreements (see above) between the federal government and individual provinces and territories. In their place, the federal government introduced the Child Care Spaces Initiative, which provides $250 million annually (for five years) to the provinces and territories to support the creation of child care spaces. This funding is in addition to other federal transfers to the provinces and territories under the Early Childhood Development Initiative and the Multilateral Framework on Early Learning and Child Care. In addition, the federal government introduced a tax incentive to businesses and organizations to create new child care spaces in the workplace.

Issues in Canadian Child Care Policy

Basic debates in the politics of child care

The issue of child care is a highly contested one in Canada. The following section provides an introduction to a few basic issues in the politics of child care.

Nature and Significance of Child Care

A fundamental issue in the context of child care is the basic nature and significance of child care services. All would agree that adequate care for children is an important social concern; however, there is often strong disagreement regarding the nature of child care services, as well as the relative significance of child care from a public policy perspective.

Some, for example, would argue that child care is about providing physical care for children. This would simply involve providing children with a healthy and safe environment while their parents are at work or in school. Others, however, take a much broader view of child care. This view considers not only physical care, but also early childhood education and development. Child care, in this sense, involves social skills development, as well as preparing children for entrance into the formal schooling system. This, in turn, can lead to very different visions concerning child care policy, especially in regards to the sorts of qualifications that child care workers require, and the types of services child care facilities should provide.

Moreover, there is also strong disagreement on the significance of child care as a public priority. Persons with children, for example, will tend to place greater importance on child care policy than those without children. At the same time, lower-income families, who depend on out-of-the-home child care in order to earn an adequate household income, may place greater importance on child care policy than affluent families who can provide child care themselves independent of public programs. This, in turn, can lead to differences concerning how much ‘political capital’ and money governments should devote to child care.

Public versus Private Child Care

From a political standpoint, a further issue in child care policy is the role of government and whether child care should be a public or private good. Most would agree that governments have some role to play in this area, particularly in regards to the regulation of child care worker qualifications, as well as health and safety standards in child care facilities. Beyond this, however, there is often strong disagreement on the extent of government involvement in child care. Some, for example, support a highly public child care system, which is managed and funded by governments. Others may support a more private system, in which parents contract out child care services to private individuals or agencies.

One could argue that a public system is vital to the creation of equitable child care in Canada, in which all families, regardless of income, have access to quality child care services. A largely private child care system, it could be argued, results in a situation in which only affluent families with the necessary income have access to quality services. Such a situation could be considered highly unfair, especially if one holds access to quality child care to be a highly valuable good. One could argue, for example, that such access is important to a child’s overall development, as quality child care can assist a child in his/her social development and prepare s/he for formal education. Moreover, that access to quality child care is important to a family’s general welfare, as it enables parents to secure care for their children while pursuing employment or training outside the home.

There are, however, also arguments against a highly public child care system. One could argue that child care is best provided by family members, as opposed to outside-of-the-home child care facilities. As such, public monies should be used to assist families in providing their own child care, rather than promoting child care outside of the home. Moreover, one could argue that a private child care system is preferable in that it provides parents with choice in child care services. Parents can select which sort of child care services best fit their own needs and preferences from the range of private providers. Finally, one may argue that equality of access to child care services can be achieved through indirect public support, such as government payments or tax benefits for parents, as opposed to a public system in which child care facilities are operated and funded by governments.

Child Care and Intergovernmental Relations

Another issue in the area of child care is the precise role of different levels of government. For some, child care policy should be a strictly provincial issue, with little federal involvement other than funding. The idea here is that residents of individual provinces and territories should be free to adopt child care priorities and strategies that best fit their own preferences, as opposed to being forced into policies decided by the federal government in Ottawa. For others, child care policy should be a national issue – one in which the federal government plays a central role in its development and implementation. The argument here often centres on creating equitable access to quality child care across the country, and the need for the federal government, in cooperation with the provinces and territories, to take the lead in creating uniform child care programs, standards, and funding for all Canadian children – regardless of where they reside.

Sources and Links to More Information

List of article sources and links for more on this topic

Sources Used for this Article

Tougas, J. (2002). “Reforming Quebec’s Early Childhood Care and Education: The First Five Years.” Childcare Resources and Research Unit. 25 July 2007. <http://www.childcarecanada.org/pubs/op17/op17ENG.pd0f>
Lauzière, M. (2000). “The Early Childhood Development Initiative: Challenges for the Voluntary Sector.” Canadian Council on Social Development. 25 July 2007. <http://www.ccsd.ca/perception/243/ecd.htm>
“Child and Family Benefits.” Revenue Canada. 20 July 2007. 25 July 2007. <http://www.cra-arc.gc.ca/benefits/>
“The Universal Child Care Plan Provides Spaces…” Government of Canada. 05 May 2007. 25 July 2007. <http://www.universalchildcare.ca/en/spaces/intro.shtml>
“About the Federal/Provincial/Territorial Multilateral Framework on Early Learning and Child Care.” Government of Canada. 11 March 2004. 25 July 2007. <http://www.ecd-elcc.ca/en/elcc/about.shtml>
“Family Allowance.” The Canadian Encyclopedia. 25 July 2007. <http://thecanadianencyclopedia.com/index.cfm?PgNm=TCE&Params=A1ARTA0002718>
“Key Economic Events: 1944 – Family Allowance Program: Supporting Canadian Children.” Government of Canada. 25 July 2007. <http://www.canadianeconomy.gc.ca/english/economy/1944family.html>

Links for More Information

2002 Mazankowski Report on Health Care in Alberta

Jay Makarenko — Sun, 01 Apr 2007 01:00:00 -0600

In 2002, several key reports on the future of health care were released, each of which outlined visions for reforming the Canadian health care system. At the federal level, there was the Report of the Commission on the Future of Health Care in Canada (the “Romanow Report”) and the Report of the Senate Standing Committee on Social Affairs, Science and Technology (the “Kirby Report”). At the provincial level, the Government of Alberta released the 2002 Report of the Premier’s Advisory Council on Health (commonly referred to as the “Mazankowski Report”). This article provides background on the Mazankowski Report, as well as an overview and analysis of its themes and recommendations.

Background on the Mazankowski Report

What is the Mazankowski Report?

Mazankowski Report Themes and Recommendations

What are the key conclusions and recommendations of the Report?

Analysis of the Mazankowski Report

How does the Report fit into the general debate on public health care?

Sources and Links to More Information

Lists of article sources and links for more on this topic

Background on the Mazankowski Report

What is the Mazankowski Report?

Premier’s Advisory Council on Health

The Mazankowski Report was produced by the Premier’s Advisory Council on Health, established, in August 2000, by former Alberta Premier Ralph Klein. The Council had a mandate to review the Alberta provincial health care system and make recommendations for both short- and long-term reform.

The Council had 12 members, including former politicians, health professionals, and academics. The Council was chaired by Donald Mazankowski, who had served in the federal cabinet of the former Progressive Conservative government helmed by Prime Minister Brian Mulroney. Since retiring from federal politics, and prior to his appointment to the Council, Mazankowski had participated in the health field, serving as chairman of the Institute of Health Economics (an Alberta-based research centre) and chairman of the Canadian Genetic Diseases Network.

For more information on the Council’s members:

Government of Alberta: Premier’s Advisory Council on Health

The Council published its final report, A Framework for Reform, in January 2002. The report is commonly referred to as the “Mazankowski Report,” reflecting the key role played by Mazankowski in its development. It is important to note, however, that the report’s final recommendations were the result of consultation with all Council members and with different organizations and individuals in Alberta’s health care field.

Council’s Mission and Activities

In preparing its report, the mission of the Council was to “provide strategic advice to the Premier on the preservation and future enhancement of quality health services for Albertans and on continuing sustainability of the publicly funded health system.” Within this context, the Council was asked to:

Assess the sustainability of the health system
Propose potential approaches and strategies
Make recommendations on a preferred vision and propose a strategic framework for health and health services in Alberta, consistent with the principles of the Canada Health Act.

In pursuing this mission, the Council:

Met with over 60 different organizations and numerous individuals representing various aspects of Alberta’s health system
Reviewed hundreds of reports and studies on health care
Reviewed information about health systems in other countries
Prepared a series of context papers on such topics as how the Alberta health system operates, how long patients wait for health services, and the views of Albertans on the health care system.

(Source: A Framework for Reform, Report of the Premier’s Advisory Council on Health)

Mazankowski Report and the Debate on Public Health Care

The creation of the Council and the release of its report occurred during a period of intense debate on the future of public health care, at both the national and regional levels. Much of this debate stemmed from concerns about the quality of public health care, including concerns about increasing waiting times for some medical services, as well as the public system’s overall financial sustainability. Tensions were high between different levels of government, with the provinces/territories demanding greater federal funding for public health care. In this context, some politicians, health professionals, and academics began to question the very foundations of Canada’s public health care system, calling for greater participation by private insurance companies and health providers.

In addition to the Mazankowski Report, several other key studies on the future of public health care were released during this period. The most ambitious was the 2002 federal report produced by the Commission on the Future of Health Care in Canada (commonly referred to as the “Romanow Commission,” as it was headed by former Saskatchewan Premier Roy Romanow). The Commission’s final report, entitled Building on Values: The Future of Health Care in Canada, was based on extensive public and expert consultation and comprised of 47 detailed recommendations.

For more information on the Romanow Report on Health Care:

Mapleleafweb: 2002 Romanow Commission on the Future of Health Care: Findings and Recommendations

Another key report to be released that year was the 2002 report of the federal Senate Standing Committee on Social Affairs, Science and Technology, commonly referred to as the “Kirby Report” (named after the Committee’s chair at the time, Senator Michael Kirby). All three of these reports, the Mazankowski, Romanow, and Kirby, contained significantly different recommendations and visions for reforming public health care.

For more information on the Kirby Report on Health Care:

Parliament of Canada: The Health of Canadians – The Federal Role

Mazankowski Report Themes and Recommendations

What were the conclusions and recommendations of the Report?

The Mazankowski Report outlines a broad range of themes and recommendations on reforming health care in Alberta. The following provides a summary of what the Report offered.

For complete details of the Report’s recommendations:

Alberta Health: Full Text of the Mazankowsi Report (PDF)

Key Themes of the Report

The Mazankowski Report identified 10 key themes regarding the Report itself and health care reform in general. These included:

Long-Term Reform: The Report is not about quick fixes or reducing costs in the short term. Instead, the objective is to reform the system over a longer term. Moreover, the Report is not about broad general ideas or approaches, but attempts to provide practical ideas and solutions to address the sustainability of the Alberta health care system.

Equitable Health Care: A central position of the Report and its recommendations is that Albertans should have fair and equitable access to health services. No one should be denied access to essential health services because they are unable to pay.

Promoting Health: The Report posits that the best long-term strategy for sustaining the health system is to encourage people to stay healthy. If Albertans and policy-makers focus simply on treating people when they get sick, the increasing costs of new treatments and technology could bankrupt the system.

Rejecting Rationing: The answer doesn’t lie in rationing health care services. People are concerned about access to health care services and rightly so. All Albertans should have access to the very best health care when they need it. And it should be available to everyone on equitable terms.

More than Efficiency: There is a need to extract maximum value for every dollar spent on health care. Such measures alone, however, will not be sufficient to match increasing demands and costs in the health care system.

New Ways of Paying: The burden of health care on the tax system is growing and will continue to grow with new treatments, new cures, new drugs, and growing demand. As such, there is a need to explore new ways of paying for health care.

Re-thinking Medicare: It’s time to think carefully about what medical services should be covered by public health insurance. The system was never designed to cover all aspects of health services, but people have come to expect that it will – and at no cost to individuals.

Innovation and Competition: There is a need to innovate. It is time to open the system up, allow health authorities to try new ideas, encourage competition and choice, and see what works and what does not.

Patient-orientation: There is a need to develop a patient-oriented system that encourages empowerment, accountability, and continuous quality improvement.

Made-in-Alberta Approach: There should not be a mimicking of other health care systems, be it those of the United States, the United Kingdom, or Sweden. Albertans and policy-makers must create their own alternative – one that preserves the best of the current system while also ensuring it can be sustained into the future.

Recommendations of the Report

In addition to the key themes identified above, the Report detailed 10 sets of recommendations for reforming Alberta’s health care system:

Staying Healthy: The first recommendation is a commitment towards healthy Albertans. Specific reforms include increased support for children in poverty, providing better public health awareness, reducing tobacco use, and providing incentives for people to stay healthy.
Putting "Customers" First: This recommendation involves understanding patients as "customers." Reforms include providing a 90-day guarantee of access to selected health services and providing more choice in the health care services they receive and where they receive them.
Reducing Services Covered by the Public Health System: The third recommendation calls for a reduction in the services a person would receive through his/her public health insurance plan. An expert panel would be established to review services currently insured and whether coverage should continue. Once a service was "de-listed," coverage would have to be through the private sector.
Invest in New Technology: This recommendation focuses upon the importance of new technology (in particular information technology) in making the health system more efficient and cost-effective. Reforms include the development and implementation of an electronic health record, and a debit-style electronic health card to track and improve health outcomes.
Encourage Choice, Competition and Accountability: The fifth recommendation would impose greater choice, competition, and accountability in the health system. Specific reforms include making regional health authorities more accountable and specialized, and blending private health care with public systems.
Diversify the Revenue Sources: This recommendation sees governments as the primary financial contributors to health, but also views funding from additional revenue sources as a viable alternative. Suggested reforms include increasing health care premiums and allowing regional health authorities to raise additional revenues.
Attracting, Retaining, and Making the Best Use of Health Providers: Suggested reforms include developing a "workforce plan" that defines the roles of various health providers and anticipates future demands on post-secondary education, improving morale, and introducing new approaches for paying physicians.
Make Quality the Top Priority for Alberta's Health System: Suggested reforms include the establishment of an "Outcomes Commission" which would measure outcomes, track progress, and report results.
Promote Alberta's Health Sector as an Asset to the Province: This crux of this recommendation is to enhance the economic benefits and spinoffs of the health care industry. Suggested reforms include the development of provincial centres of excellence in health research, and the commercialization of new products and services developed through medical research.
Establish a Clear Transition Plan: The final recommendation is administrative. Specifically, it calls for continued studies concerning the implementation of the reforms, informing the public when changes occur, and addressing barriers to implementation.

Analysis of the Mazankowski Report

How does the Report fit into the general debate on public health care?

Comparison to Current Health Care System

Does the Mazankowski Report represent a radical shift in health care policy, or does it simply involve making current approaches better? The answer is not that clear. On the one hand, the Report explicitly states that it is committed to the principles of Canada’s contemporary health care policy, in particular, the tenets of the Canada Health Act. Yet, on the other hand, the Report makes some recommendations which, if adopted, would seem to radically alter the health care system.

The Report’s mandate was to make recommendations for reform that were consistent with the Canada Health Act. The Act prohibits user-fees and extra-billing while requiring provincial/territorial health insurance plans to be publicly administered, comprehensive, universal, portable, and accessible. Generally speaking, then, there seems to be a commitment to the basic tenets of Canada’s contemporary health care system.

For more information on the Canada Health Act:

Mapleleafweb: The Canada Health Act: Provisions and Administration [insert link when published]

Moreover, the Report explicitly states that Albertans should continue to have fair and equitable access to health services, while regarding governments as the primary funders of health care in the province. Again, these are basic tenets of Canada’s contemporary health care system (although, the Report does not clearly define what it means by such things as “fair” and “equitable,” or governments being the “primary” funders of health care). The Report also highlights several non-controversial reforms, which, if implemented, would not radically alter the current public health care system. These include reducing health costs by promoting the general health of Albertans, searching for ways to maximize health care dollars (without reducing quality of service), and investing in new technologies to increase system efficiencies.

The Report does, however, make several key recommendations that might significantly alter the foundation of the current public health care system. For example, the Report suggests that more competition should be introduced in the system as a means of improving innovation, quality, and patient choice. Moreover, it suggests that increased participation by private medical providers would enhance this competition. Such a reform, however, pushes the boundaries of the traditional Canadian health system, which is, to a large extent, a public-monopoly of government health insurance plans and health providers (at least, in the context of medically necessary and hospital-provided health services).

The Report also makes several recommendations that may, in fact, be construed as violating the Canada Health Act. For example, the Report suggests that health authorities should be allowed to diversify their revenue streams beyond direct government funding. One might perceive this as opening the door to user fees, which are prohibited under the Canada Health Act. The Report also recommends re-thinking what services would be provided under Alberta’s public health insurance plan. Extensive de-listing of medical services could be a violation of the comprehensive requirement of the Canada Health Act.

Market-consumerism and Health Care

It is also important to draw attention to the basic language used by the Report, which provide some indication of what sort of health care system it is advocating. In several places, the Report discusses health care in terms common to market economics and consumerism. For example, it often talks about patients as “customers” of health care, whom should be provided with greater “consumer choice.” Moreover, it often references the health care system in terms of market dynamics, with different health providers “competing” with one another for “customer business.”

This type of language differs significantly from other approaches that view health care more in terms of a publicly provided, citizenship-based good. Under this alternative view, the focus is not on market competition and consumer choice, but on “social cooperation” and “citizen entitlements” to a certain standard of health care. Moreover, this sort of language is more closely associated with health care systems that are funded and administered by public entities (such as governments), than those based on competition between private medical service providers.

The point here is not to condemn or praise the Report for this language of market-consumerism, but simply to raise attention to the fact that there are different means of talking about health care. Moreover, these different languages often involve very different priorities for the health care system. The Mazankowski Report uses the language of market-consumerism, and, as a result, seems to place great emphasis on elements such as consumer choice and market competition in its suggested approach to reforming Alberta’s health care system.

Sources and Links to More Information

Lists of article sources and links for more on this topic

Article Sources

Premier’s Advisory Council on Health. “A Framework for Reform: Report of the Premier’s Advisory Council on Health.” Alberta Health. December 2001. 10 May 2007. <http://www.health.gov.ab.ca/resources/publications/PACH_report_final.pdf>
“Premier’s Advisory Council on Health Releases Comprehensive Report on Health Reform.” Government of Alberta. 8 January 2002. 10 May 2007. <http://www.gov.ab.ca/acn/200201/11771.html>

Links to More Information

Mapleleafweb: The Canada Health Act: Provisions and Administration [insert link when published]
Mapleleafweb: 2002 Romanow Commission on the Future of Health Care: Overview of Findings and Recommendations [insert link when published]
Alberta Health: A Framework for Reform: Report of the Premier’s Advisory Council on Health (PDF)
Government of Canada: Report of the Premier’s Advisory Council on Health (Alberta) – An Overview