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

In 2002, the Commission on the Future of Health Care in Canada, headed by former Saskatchewan Premier Roy Romanow, released two reports on the nation’s health care system. The Commission’s findings and recommendations have taken a central place in the debate on the value and future of Canada’s public healthcare system. The purpose of this article is to provide an introduction to the Commission’s key findings and recommendations and, in so doing, review the Commission’s organization and activities, as well as summarizing both its interim report, Shape the Future of Health Care, and its final report, Building on Values: The Future of Health Care in Canada.

Background on the Romanow Commission on Health Care

What was the Commission on the Future of Health Care?

Summary of the Romanow Commission’s Interim Report

Shape the Future of Health Care

Summary of the Romanow Commission’s Final Recommendations

Building on Values: The Future of Health Care in Canada

Sources and Links to More Information

Sources for this article and links for more on this topic

Background on the Romanow Commission

What was the Commission on the Future of Health Care?

The Commission on the Future of Health Care in Canada was a federal public inquiry created in April 2001 to review and make recommendations regarding Canada’s public health care system. The Commission, headed by former Saskatchewan premier Roy Romanow, was created by the Chrétien Liberal government as part of the Prime Minister’s pledge to address the long-term sustainability of public health care in Canada.

The Commission engaged in extensive public and expert consultation over the course of 18 months, producing two reports: an interim report entitled Shape the Future of Health Care (February 2002), and a final report, Building on Values: The Future of Health Care in Canada (November 2002). These summarized the Commission’s findings on the state of Canada’s health care system, in addition to offering 47 recommendations on how to enhance health care in Canada.

The Romanow Commission’s Mandate

The Commission’s mandate was outlined in its terms of reference, which stated the following:

“… to inquire into and undertake dialogue with Canadians on the future of Canada’s public health care system, and to recommend policies and measures respectful of the jurisdictions and powers in Canada required to ensure over the long term the sustainability of a universally accessible, publicly funded health system, that offers quality services to Canadians and strikes an appropriate balance between investments in prevention and health maintenance and those directed to care and treatment…” (Canada Privy Council, Order in Council P.C. 2001-569)

Generally speaking, then, the Commission’s mandate was one of policy review, to review government policies and programs in the arena of health care. Under this general mandate, the Commission was given two specific objectives. Firstly, to inquire into, and gather information regarding, the future of Canada’s public health care system. Secondly, to make recommendations to government in regards to the public health system’s long-term stability.

The terms of reference also set out certain criteria in fulfilling these objectives. Most important was the requirement that the Commission engage in extensive “dialogue” or consultation with the general public, recognizing that the views of ordinary Canadians should have a strong influence on the Commission’s final recommendations. In addition, the terms of reference placed certain limits on the sorts of recommendations the Commission could provide. They were to: 1) be respectful of the jurisdictions and powers of different levels of government; 2) maintain universal assess to the health system; 3) ensure quality medical services for Canadians; and, 4) strike a balance between investments in prevention and health maintenance. Beyond this, the Commission was free to put forth any recommendations it found appropriate.

For the official statement of the Commission’s mandate:

The Romanow Commission’s Powers

In performing this mandate, the Commission was given extensive administrative and creative powers. It was authorized to organize itself in any manner it saw fit, to consult any party it felt relevant, and to use any means of research and public consultation it deemed useful. Moreover, the Commission was largely independent from government; it was, for example, free to be critical of federal and/or provincial/territorial governments and their health policies.

Beyond these administrative and creative powers, however, the Commission had very little legal authority. As a public inquiry, the Commission did not have the power to force governments to act on its conclusions and recommendations. Federal, provincial and territorial governments were free to accept the Commission’s conclusions and act upon them, or disregard them entirely, or in part. As such, the Commission can best be regarded as a high-profile medium for discussion and advice on health care policy.

Commissioner Roy Romanow

Roy Romanow, former Premier of Saskatchewan (1991-2001), was the appointed head of the Commission. Under the Commission’s terms of reference, Commissioner Romanow was given extensive administrative powers to:

  • Appoint advisers and create advisory mechanisms as he deems appropriate for the purpose of the inquiry;
  • Consult with provinces and territories and groups and individuals having an interest in or responsibility for health care in Canada and to use the means and vehicles required to ensure that a dialogue with Canadians occurs during the course of the inquiry;
  • Adopt such procedures and methods as he may consider expedient for the proper conduct of the inquiry, and to sit at such times and in such places in Canada as he may decide;
  • Rent such space and facilities as may be required for the purposes of the inquiry, in accordance with Treasury Board policies; and,
  • Engage the services of experts and other persons as are referred to in section 11 of the Inquiries Act, at such rates of remuneration and reimbursement as may be approved by the Treasury Board.

As its central figure, Commissioner Romanow was highly associated with the Commission’s work and final recommendations. The Commission itself was commonly referred to as the “Romanow Commission” and its final recommendations as the “Romanow Report.” While his influence over the Commission and its direction was unquestioned, it is important to note that Romanow worked in collaboration with other Commission personnel, and that the final report was based on both extensive expert and public consultation.

For biographical information on Commissioner Roy Romanow:

Romanow Commission Quick Facts

  • Length: The total lifespan of the Commission was approximately 18 months, beginning in April 2001 when the Commission was first created and ending in November 2002 when it delivered its final report.
  • Public Hearings: The Commission held 21 days of public hearings in 18 different cities across Canada; 12 days of citizen-based focus groups, in which 480 Canadians took part; and 12 on-campus policy dialogues at different Canadian universities.
  • Expert Hearings: The Commission held nine workshops with provincial officials and other experts, as well as six expert roundtables (three in Canada and three overseas).
  • Research: The Commission received 40 discussion papers, three major independent Research Consortium reports, nine issue/survey papers, 640 formal submissions, 591 formal presentations, 1,418 abstracts, and 14,000 online health issue surveys.
  • Reports: The Commission prepared two official reports totaling 474 pages in length: an interim report (82 pages) and a final report (392 pages).
  • Commission Staff: 35 full-time staff were employed during the Commission’s peak periods. Other consultants were employed on an as-need basis for a range of duties, including research, logistics, and communications.
  • Total Cost: The total cost of the Commission was $15 million.

Summary of the Romanow Commission’s Interim Report

Shape the Future of Health Care

Overview of the Interim Report

The Commission on the Future of Health Care in Canada produced two official reports, the first of which was an interim report, released in February 2002, titled Shape the Future of Health Care. This was a purely fact-finding and synthesis report, providing an overall summary of key issues concerning the future of the Canadian health care system. Formal recommendations for reform were provided in the Commission’s final report, released in November 2002.

The interim report was divided into four substantive sections, each focusing on a particular issue in healthcare policy. These included: 1) basic values regarding health care; 2) funding and fiscal stability; 3) health care quality and access; and, 4) leadership, collaboration, and responsibility.

For the full details of the Commissions interim report:

Values and How They Shape the Views of Canadians

An important element of the Commission’s interim report was an examination of the values of everyday Canadians in the context of health care. The Commission found there was strong agreement on basic beliefs and concerns, but also strong disagreement regarding the particulars of health care reform.

The Commission found that most Canadians agreed on the following basic beliefs and concerns:

  • The poorest in society should have access to healthcare
  • Individual Canadians should not be bankrupted by the cost of acquiring needed healthcare services
  • Need should be taken into account in determining what medical services should be covered by public health insurance
  • Both orders of government (federal and provincial) must play a role in reforming the health care system

The Commission, however, found that within these shared beliefs and concerns, there were strong disagreements. Canadians often differ over the basic language used in the health care debate. For example, it was determined there was a lack of consensus over the notion of “need” when determining what medical services should or should not be covered. While some equated “need” with an individual’s own preferences (what they “want” is what they “need”), others held the view that “need” should be determined by skilled and knowledgeable professionals who give credence to a patient’s circumstances. Still others argue that “need” should be based on objective criteria that are applied equally to all persons. Similar disagreements were also identified regarding other core concepts in health care, including “fairness” and “access.”

Canadians also disagreed on how to address the challenges facing the health care system. The Commission highlighted four major perspectives around which the views of the majority seemed to coalesce:

  • Greater public investment: One perspective is that the primary challenge facing the health care system is inadequate funding. The system would work well if only it had more money. The solution, therefore, lies in adding more resources and public money to the present system.
  • Shared costs and responsibilities: A second perspective is that Canada’s traditional health care system is financially unsustainable and will collapse under the cost of new technologies, new health problems, new expectations and improper use. A better solution, therefore, is to add more resources, not by increasing public investment, but by asking individual Canadians to bear a larger financial burden through options such as user-fees and private insurance.
  • Increased private choice: A third view is that the discipline of the marketplace would improve the effectiveness and efficiency of the public healthcare system. This would require providing Canadians with greater choice in their health care services through the development of private health provides that would compete alongside the public system. Supporters believe this approach would relieve pressure on the public system and introduce a more entrepreneurial ethic into health care that would spur greater private investment and innovation.
  • Reorganize service delivery: The fourth perspective favours fundamentally reforming the organization and delivery of health care with the objective of creating a cheaper and more effective system. Advocates of this perspective argue that a traditional “fee-for-service” system for paying doctors is an out-modelled concept that provides few incentives to focus on “wellness” and often leads to inappropriate and more expensive care.

The Commission concluded, however, that it was doubtful any one of these perspectives alone provided a complete solution to the challenges faced by the health care system.

Health Funding and Fiscal Sustainability in Canada

The Commission also examined the issue of funding and fiscal sustainability in the public health care system. In so doing, the Commission outlined several funding-related challenges:

  • Increasing healthcare spending/costs: Health spending in Canada increased significantly over the period of 1976 to 2002, both in terms of spending per capita and as portions of government budgets (in particular, provincial budgets). Furthermore, current trends show that costs will continue to rise in the future due to the expense of new medical therapies and technologies, the aging of the Canadian population, and rising expectations in the quality of health services. This raises several key issues, such as how to manage health care costs, determining what portion of overall public spending should be dedicated to health care, and deciding what level of health services should be expected.
  • Unstable health funding: In comparison to other advanced industrialized countries, Canada exhibits sharper changes in annual public health spending (meaning spending often increases or decreases sharply from year to year). For the Commission, this represents a challenge for health care planners in Canada, as they are constantly facing unstable and unpredictable levels of health funding. The basic premise is that it is difficult to plan for the future when one is unsure of how much money will be available.
  • Complexity of health funding: The Commission also found health care funding in Canada to be a complex system of private and public insurance schemes, federal/provincial/territorial funding agreements, and tax and premium schemes. The Commission found this complexity to be problematic in that it results in very little transparency regarding how much money is being spent, by whom, on what basis, and with what results.
  • Solutions to funding: The Commission concluded that there are no simple, easy solutions to the issues of funding. Moreover, it arrived at the conclusion that the solution does not lie in different levels of government pointing fingers at one another, but in implementing better processes to determine the relative federal and provincial/territorial shares for maintaining a viable and effective health care system.

Health Care Quality and Access in Canada

In addition to health funding, the Commission examined issues regarding the quality of health care and access to the health system. In this context, the Commission outlined several key concerns, including:

  • Waiting for health care: The Commission recognized that excessive delays in receiving health care services are one of the main concerns of Canadians. This includes waiting to see a specialist, to receive diagnostic procedures (such as MRIs), to get elective, non-emergency surgery, to receive care in hospital emergency rooms, and to gain access to long-term care facilities. The Commission further recognized that these delays are caused by a number of different factors, such as a shortage of resources in the health system and inefficient management practices.
  • Other access issues: The Commission also highlighted other access issues, such as regional disparity (better access to services in urban areas than in rural regions), some essential services not being publicly covered under provincial/territorial health insurance (such prescription drugs for chronic illnesses), and cultural, linguistic and class barriers, which can often make it difficult for some marginalized groups (such as Aboriginals and immigrants) to access health services.
  • Measuring outcomes: The Commission recognized that, despite recent efforts, there continues to be an absence of good, reliable, comparable information on many aspects of the health care system, such as waiting times, health costs, and treatment outcomes. As a result, there is very little hard evidence to guide decision making on how to improve the quality of health care and access to the system.
  • Health human resources: The Commission found that human resources in the health care sector to be a key factor in health care service delivery, both in terms of quality and accessibility. On the one hand, there is the problem of shortages of key health professionals, including doctors, nurses, therapists, and technicians. These shortages are especially acute in remote and rural communities. Moreover, there is a growing morale problem among health professionals that can be attributed to longer working hours, increasingly stressful working conditions, and the sense of being left out of the process of health reform.
  • Primary health care reform: The Commission emphasized the need to examine the issue of primary health care reform. Primary Healthcare is a broad approach to that includes the integrated services of health promotion and illness/injury prevention, as well as traditional health maintenance (such as basic diagnosis and treatment). It involves all services that directly and indirectly affect health, such as traditional medical services, income, housing, education, and the environment. The Commission concluded that there is a need to identify and remove barriers to the expansion of primary health care initiatives across the country.
  • Home and palliative care: The Commission recognized the need to address the issues of home and palliative care. Homecare involves treatment of patients in their homes, which can mean shorter hospital stays, increased quality of care, and significantly lower costs to the health care system. According to the Commission, however, the basic infrastructure to support homecare is highly uneven or non-existent in some communities. The Commission also considered palliative care, or care for persons at the end of their lives, a related issue. The Commission recognized that many feel that quality palliative care is a right of every Canadian and that greater effort should be made to enable the terminally ill to spend the last moments of their lives at home with friends and family. The Commission concluded that Canadians must make a decision on whether to establish national policy directions and extend public funding to expand home and palliative care.
  • Health research: The Commission found that research in the arena of health and health care holds tremendous potential for curing illness, preventing illness, and improving overall quality of life of Canadians. The Commission concluded that Canada needs to maintain research as a hallmark of Canada’s health system.

Leadership, Collaboration and Responsibility in the Health Care System

Finally, the Commission examined issues of leadership in the health care system, such as who leads the system, how decisions are made in health policy, and what responsibilities different players have. Generally speaking, the Commission found that Canada’s health care system is characterized by a complex and confusing array of decision-makers, whom have little direction and accountability – actors who often co-exist in a relationship of tension, rather than collaboration. More specific findings by the Commission include:

  • Federalism: The Commission found the existing system of leadership too frequently results in mounting tensions between provincial and federal governments, with an emphasis on governmental jurisdictions and powers. The Commission concluded that there needed to be a new and more collaborative approach between governments, in which all worked together as equal partners for the benefit of the health care system as a whole.
  • Aboriginal health: There exists uncertainty regarding responsibility for Aboriginal health and health care programs, which has serious consequences for Aboriginal peoples. While the federal government has gradually transferred some control over health care to Aboriginal authorities, defining which persons qualify for what federally-funded health services is complex. Many Aboriginal persons find themselves relying on provincial health programs that do not reflect their unique needs.
  • Globalization: The Commission found that globalization and trade liberalization present both opportunities and constraints for the future of health care. For example, the Commission highlighted the potential of international trade agreements to constrain Canada’s ability to reform and innovate its health care system.

Summary of the Romanow Commission’s Final Recommendations

Building on Values: The Future of Health Care in Canada

Overview of the Report

The Commission’s final report, Building on Values: The Future of Health Care in Canada, was tabled in the House of Commons in November 2002. The report comprised 47 detailed recommendations, as well as estimated costs and timeframes for their implementation. These recommendations covered a broad range of issues pertaining to the health care system, from its basic legislative framework, to government financing and cooperation, to health information and research, to rural and Aboriginal health.

Generally speaking, the Commission accepted the basic framework of the nation’s current health care system. The Commission strongly supported a publicly administered and financed universal health care system, with its cornerstone being Medicare (the regime of provincial/territorial health insurance plans). The Commission did not advocate the privatization of health care, be it through a two-tier or ‘American-style’ system. Moreover, the Commission supported the current inter-governmental approach to health policy and funding. The Commission did not, for example, advocate designating health care as either a strictly federal or provincial/territorial responsibility.

Within this basic framework, however, the Commission recommended significant and comprehensive reforms to the current structure and operation of the public health care system. In making its recommendations, the Commission sought to achieve several goals, including: improving public administration of the system; making health care policy and delivery more responsive and accountable to Canadians; improving health care access and quality; and, ensuring the system’s financial stability.

The following provides an executive summary of some of the Commission’s key recommendations. For an outline of all of the Commission’s final recommendations, as well as the specific details of each, consult:

Legislative Frameworks Governing Health Care

One theme in the Commission’s report was the need to update and strengthen the legislative frameworks governing health care, so as to provide a clear vision, written in law, of the basic values, rules, and responsibilities. Specific recommendations in this area included:

  • Health Covenant: Enacting a new Health Covenant that would set out the basic framework of the Canadian health care system. This Covenant would clearly outline the nation’s collective vision for the future of health care, and the responsibilities and entitlements of individual Canadians, health providers, and governments.
  • Canada Health Act: Updating and clarifying the Canada Health Act, the federal legislation governing provincial/territorial health insurance plans. Key reforms suggested include: limiting the principle of portability to guaranteeing portability of health coverage to just within Canada; expanding the principle of comprehensiveness to include diagnostic services and home care; adding a new sixth principle of accountability; and, adding an effective dispute resolution process to regulate federal-provincial/territorial relations.

For more information on the Canada Health Act:

Canadian Federalism and Health Care

In addition to strengthening the legislative frameworks governing health care, the Commission also addressed the roles of different levels of government in health policy. While respecting traditional constitutional jurisdictions and powers, the Commission did advise changing the manner in which the federal, provincial and territorial governments work together in health care. In particular, it stressed the need for a collaborative approach – one where all levels of government work together as equals in the development and implementation of health policy.

More specifically, the Commission recommended creating a new Health Council of Canada, with the goal of fostering communication and cooperation between governments, as well as depoliticizing and streamlining key aspects of the intergovernmental process. The proposed Council would be responsible for the impartial collection and analysis of data on the performance of the health care system; providing strategic advice and analysis to federal, provincial, and territorial governments; and, for seeking ongoing input from the public.

According to the Commission, the proposed Council’s Board would be appointed through a consensus of federal, provincial, and territorial governments, and should include representation from the general public, the academic, scientific and professional communities, and appropriate regional representation from across the country.

Health Care Funding and Financing in Canada

In regards to paying for health care, the Commission supported continuing the current “public” approach, in which basic medical services are covered through a series of provincial and territorial health insurance plans financed by public tax dollars. The Commission did not support “privatizing” health care costs by allowing for comprehensive private insurance schemes financed through health premiums.

The Commission, however, did support reforming the structure of public funding in health care. The Commission recognized an obligation on the part of the federal government to increase its financial contribution to health care costs, so as to offset some of the provincial/territorial burden. Moreover, the Commission supported a more stable system of public funding to enable effective long-term health care planning, as well as several short-term public funding initiatives to address immediate concerns. Specific recommendations include:

  • Federal Health Transfer: Improve funding stability and equity through reform of the federal financial transfers to the provinces and territories for health care.  This new federal transfer would be cash-only, as opposed a combination of cash and tax point transfers (tax point transfers can make funding less stable and predictable). Moreover, the federal transfer would require an increased share of federal funding for health care (the Commission recommended a minimum federal contribution of 25 percent of provincial/territorial healthcare costs), as well as an ‘escalator’ provision which would increase funding at a set rate to ensure stable funding over the long-term.
  • Immediate targeted funding: In addition to improving the system of long-term funding, five new targeted funds should be established to address immediate concerns in the health care system. These programs would be supported by a core of federal funding, with provincial/territorial commitments to match or exceed federal monies. The new funds would include a:
    • Rural and Remote Access Fund: to improve timely access to care in rural and remote areas.
    • Diagnostic Services Fund: to improve waiting times for diagnostic services (such as MRIs).
    • Primary Health Care Transfer: to provide the funding needed to accelerate the development and implementation of Primary Care beyond the stage of pilot projects.
    • Home Care Transfer: to provide the foundation for an eventual national home care strategy.
    • Catastrophic Drug Transfer: to allow provincial and territorial drug programs to expand and improve coverage for their residents, particularly in regards to health conditions that can lead to serious or “catastrophic” financial burdens.

Primary Health Care and Prevention

Another key element identified in the Commission’s report was the need to transform Canada’s health care system to focus squarely on primary health care strategies. Primary health care is a broad approach that goes beyond traditional notions of health care. In addition to regular health maintenance, such as diagnosis and treatment, it places a strong emphasis on health promotion and illness/injury prevention. In doing so, Primary health care includes all services that are directly and indirectly related to health, such as traditional medical services, income, housing, education, and environmental factors.

For more information on Primary health care:

In this context, the Commission made several key recommendations. These include:

  • Primary Health Care Transfer: The new Primary Health Care Transfer (see above) would provide the necessary funding to accelerate primary health care delivery beyond the stage of pilot projects, with the goal of achieving permanent and lasting change.
  • National platform: While each region of the country is different, the Commission concluded that four essential building blocks should define primary health care across the country. These include: a) continuity of care; b) early detection and action; c) better information on needs and outcomes; and, d) new and stronger incentives for health care providers to participate in primary health care projects. To mobilize change in this area, a national summit should be convened by the proposed Health Council of Canada (see above).
  • Prevention and promotion initiatives: Canada’s health care system should place greater emphasis on prevention and health promotion initiatives. Targeted actions should be taken to reduce tobacco use and rates of obesity, and encourage Canadians to live more active lifestyles.
  • National immunization strategy: Governments should work together to create a new immunization strategy to ensure that Canada is well prepared to face new and emerging problems resulting from globalization and the evolution of infectious diseases.

Health Care Access and Quality Health Care in Canada

The Commission also made several recommendations in regards to waiting times, access, and quality issues in the health care system. These include:

  • Diagnostic Services Fund: Long waiting times for essential diagnostic services (such as MRIs) is due in part to an under-investment in diagnostic technologies. The new Diagnostic Services Fund (see above) should be used to purchase new equipment and to train the necessary staff and technicians.
  • Management of waiting lists: There should be greater standardization and coordination in the management of waiting lists. Steps should be taken to establish centralized approaches within health regions, on a province-wide basis, or even, in some cases, on a national basis. There should be a recognized right for patients to good information about expected wait times for treatment and the full range of options available to them.
  • Measuring and tracking results: Improvement to the health care system cannot effectively take place without the proper measurement and tracking of results. The proposed Health Council of Canada (see above) could be used to work with the provinces and territories to collect comparable information and report regularly to Canadians on their health system.
  • Addressing diversity: The health care system should match the needs of different groups of Canadians, from men and women, to new Canadians and visible minorities, to different linguistic groups and people with disabilities.

Other Key Recommendations in the Romanow Commission

Other key areas of recommendation in the Commission’s report included:

  • Prescription drugs: Begin the process of integrating coverage for prescription drugs within Medicare in a uniform manner across all jurisdictions. Specific recommendations include using the proposed Catastrophic Drug Transfer to offset the cost of provincial and territorial drug plans and reduce disparities in coverage across the country. Other suggested approaches include: establishing a National Drug Agency to control costs and to evaluate new and existing drugs, and reviewing aspects of national patent laws to improve access to generic prescription drugs while containing costs.
  • Homecare: Recognize and develop homecare as an essential service in the Canadian health care system. Specific recommendations include using the proposed Home Care Transfer to ensure all Canadians have access to common homecare services; revising the Canada Health Act to include three elements of homecare as necessary medical services (home mental health management and intervention services, post-acute homecare, and palliative homecare); and providing benefits in support informal caregivers (family and friends) who deliver homecare (allowing, for example, such informal caregivers to have time off work and special benefits through the Employment Insurance program).
  • Aboriginal Health: Address the serious disparities in health for Canada’s Aboriginal peoples. Specific recommendations include consolidating health funding from all federal, provincial/territorial, municipal, and band sources into a new Aboriginal Health Partnership; establishing a clear structure and mandate for this Partnership; and ensuring ongoing input from Aboriginal peoples into the direction and design of health care services in their respective communities.
  • Rural Health: Improve health care in rural and remote areas through the proposed Rural and Remote Access Fund (see above) by addressing the shortage of qualified health professionals and expanding Telehealth to improve access to care.
  • Globalization: Address issues regarding Canada’s health care system in the global context. Specific recommendations include ensuring that Canadians will not be constrained by international law and trade agreements in the organization of their health care system; playing a leadership role in improving health care in developing nations; and solving health professional shortages domestically rather than recruiting from developing nations (which has caused shortages in those nations).

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