Scott a wolfe enhancing primary care and health equity in canada wellesley institute may 2010

Policy Paper Enhancing Primary Health Care → Enhancing Health Equity in Canada By Scott A. Wolfe May 2010 | August, 2009

Table of Contents Overview .............................................................................................................. ..1 Health Equity Into Action ............................................................................................... 2 Health Equity Into Action I: Social Determinants of Health ........................................... 3 Health Equity Into Action II: Enhancing Primary Health Care......................................... 3 PHC reform in context: the impact of ―social determinants of health‖ .................... 5 Action Pillar #1: Establishing a civic framework for primary health care reform, grounded in health equity .......................................................................... 7 Action Pillar #2: Reform of Primary Health Care services and programs ............. 11 Improve overall integration of primary clinical care with health promotion and community development programs ..................................................................... 12 Implement an appropriate mix of PHC delivery models to meet diverse population and community needs .............................................................................. 14 Expand interprofessional primary health care…………………………………………... 18 Improve and expand community engagement in planning and delivery of PHC services and programs ...................................................................................... 20 Improve collection and quality of health information to better inform action on health inequities, particularly at the level of primary health care ........................... 22 Committing to action, getting started……………………………………………….....23 Endnotes .............................................................................................................. 25

Overview In 2008, the World Health Organization (WHO) selected primary health care (PHC) as the focus of its annual World Health Report. This reflected broad consensus that reform of this level of health care—what people often identify as their family physician‘s office, community health centre or local walk-in clinic—is a top priority for countries around the globe. An effective PHC system is key to improving the health of the population as well as the overall effectiveness and sustainability of the health system since it is the main entry point to care, plays a critical role in preventing illness or progression of illnesses, and pulls together a fragmented health system.1,2 One of the critical problems across Canada and in other wealthier countries is pervasive and damaging health disparities. The roots of inequitable health outcomes and opportunities lie far upstream in deep-seated social and economic inequality, and policy action is needed to address these foundations. But those populations most affected by these wider inequalities tend to have poorer health, and often also need more complex health care and support. There are also systemic disparities in access to and quality of health care. Therefore, while broad social policy changes are required to address the root causes of poor health, a great deal can and must be done within the health system itself to enhance health equity.3 Considerable international evidence demonstrates that one of the most important directions that can be taken within the health system to reduce disparities is to enhance access to primary health care, especially for the most marginalized and disadvantaged communities. In its 2008 global report, the WHO affirmed that while universal access to health services must be a top priority for health systems, it is critical to move beyond a narrow focus on simply increasing access to PHC services. In other words, having access to these services is not enough. Instead, we must place increased attention on how PHC services are delivered, as well as their connection to the various social and environmental determinants that contribute to health and health disparities in the first place. This means understanding and organizing PHC not just as ―first line‖ health services, but as a broader nexus of services, supports, programs and policies that promote good health for all. For a PHC system to play its optimal role, primary clinical services must be coupled and coordinated with practical health promotion programs, community development and planning, and public policies which address the deep connections between our daily, lived realities, and the impact of those realities on our health. In other words, PHC is a crucial means of concretely addressing underlying social determinants of health at a community and local level and in taking these determinants and community contexts into account in delivering health care and building healthy communities.

This system must be flexible, adaptable and coordinated to ensure that all individuals and groups are able to receive the care and support they require, depending on their diverse, lived social realities and their particular health concerns. The goal must be health, in the sense of overall well-being, not simply preventing or curing illness. Building on current global momentum related to PHC reform, including the 2008 World Health Report, this paper outlines some key concerns and opportunities for effective PHC reform in the Canadian context. Fundamentally, I argue that PHC in Canada must be grounded in a ―health equity approach‖ and long-term commitment to a shared vision for health system renewal. The need for this grounding in health equity and a longer-term vision is underscored by pervasive health disparities across Canada. Health equity is concerned with reducing those disparities that are avoidable, unfair and systematically related to social factors such as poverty, inadequate housing and discrimination on the basis of race, gender or other dimensions of inequality.4 Canadian governments, federally and provincially, share a profound responsibility for remedying these health disparities; a responsibility that is implicit in the Canada Health Act, and more explicitly elaborated within other important Canadian commitments, including our Charter of Rights and Freedoms and numerous international declarations to which Canada is a signing party. In Ontario, the recently passed Excellent Care for All Act included equity and a population health focus as key principles for the provincial health system. A health equity approach to PHC reform is an extension of the values and principles collectively espoused in diverse Canadian treatises and agreements, affirming every Canadian resident‘s right to health, the necessary resources for well-being, and access to appropriate health care and support. Adopting a ―health equity approach‖ to PHC reform is not only critical to remedying health inequities, but also to better organizing and coordinating the nexus of programs, services and policies that make up PHC. In this way, all Canadians stand to benefit since these reforms will make better use of our shared health system resources and be geared toward keeping Canadians and our communities healthy in the first place. Health Equity Into Action While this paper sets out key principles that must be accepted as a basis for the health equity approach to PHC reform in Canada to take root, it does not dwell on theory. Instead, I move quickly from principle to practice, outlining ―twin pillars of action‖ for this health equity approach to PHC reform in Canada. 2

Health Equity Into Action I: Social Determinants of Health The first pillar focuses on the need to address the underlying social determinants of health and health inequality through a long-term civic engagement strategy and enduring mechanisms for inter-sectoral public policy. This civic framework, and these mechanisms for public policy are intended to address the social determinants of health in all their complexity. The broad goals of a proposed civic framework are to focus social and political attention on the ways in which inadequate housing, poverty, inequitable education, racism and other social factors affect our health, and to engage the Canadian public and policy makers more deeply in an ongoing conversation about our health (not just health care) as a shared social responsibility. By highlighting these dimensions of reform (what to some readers might appear oddly situated outside of a health care discussion) I wish to emphasize that PHC reform is as much about civic Health and illness are renewal, about health as a shared social political decisions, rooted goal, and about purposeful government in our commitment (or policy action, as it is delivery of a certain set lack thereof) to tackle and of health ―services‖. mitigate root causes such At the same time, these broader civic and as poverty, inadequate policy mobilization efforts, necessary to housing and other forms drive change around the roots of health of social exclusion. inequity, must be coupled with practical reforms within the health system itself. Health Equity Into Action II: Enhancing Primary Health Care Therefore, the second pillar of action focuses specifically on practical steps that policy makers and health system stakeholders can take to enhance and re-orientate PHC services and programs as part of the overall transformation of the health care system. Five key measures are recommended: 1. Improve overall integration and coordination of primary clinical care with health promotion and community development programs; 2. Implement an appropriate mix of PHC delivery models to meet diverse population and community needs; 3. Expand inter-professional primary health care; 3

4. Improve and expand community engagement in planning and delivery of PHC services and programs; 5. Improve collection and quality of health information to better inform action on health inequities, particularly at the level of primary health care. These five steps do not constitute an exhaustive list of reforms that are required. Rather, they are several of the most urgent and practical measures that health system stakeholders can take. In combination, these two pillars of action — development of a broad policy and civic framework addressing fundamental social determinants of health, on the one hand, and specific health system steps, on the other — are mutually re-enforcing, and form the basis of an effective, modernized PHC system. In proposing these pillars of action for a health equity approach to PHC reform, I do not under-estimate or minimize the challenges. These include a broad and deeply entrenched bias toward physician-driven primary care in Canada, as well as the complexity of organizing diverse policy makers around health as a common goal in the face of competing priorities and interests. Realizing the potential of these action pillars will no doubt be a matter of incremental progress, rather than quick fixes. However, this is no excuse for inaction or delay. Tomorrow‘s success begins with today‘s courageous steps forward. Grounding commitment in a shared vision Because a health equity approach to PHC reform in Canada will require commitment across generations, successive governments, and political parties, a binding vision for health and health system reform is necessary. This binding vision will help Canadians remain focused on the longer term project. Fortunately, such as vision already exists. In fact, it is etched into the very DNA of our Medicare system, planted there over fifty years ago by the system‘s founders, including Tommy Douglas and Emmett Hall. As Douglas, Hall and others breathed life into Medicare almost 50 years ago, focusing first on the key issue of universal access to doctors, hospitals and other public health care coverage, they foretold the future of Canada‘s health system. They argued that the system would eventually need to evolve toward what they termed a ―Second Stage or Phase of Medicare‖.5,6 In this second stage, Canadians would have to go beyond merely guaranteeing access to public health care coverage, through public insurance, instead tackling the challenge of actually reforming services, supports and policies so that we do a better job keeping people healthy in the first place. The vision of this Second Stage of Medicare, I assert, must be woven into all efforts related to the two pillars of action on PHC reform. Not only should government, but all 4

political parties would be prudent to adopt the language and spirit of the Second Stage of Medicare as a quintessential characteristic of our shared, Canadian identity; what the Honourable Roy Romanow has referred to as the Canadian belief in a ―shared destiny‖ and a spirit of ―sharing and caring‖.7 By effectively acting on a health equity approach to PHC reform and committing to a realization of the Second Stage of Medicare, Canadians may regain our position as global leaders in health care and health. PHC reform in context: the impact of “social determinants of health” “Primary health care reforms aim to channel society’s resources towards more equity and an end to exclusion; towards health services that revolve around people’s needs and expectations; and towards public policies that secure the health of communities. Across these reforms is the imperative of engaging citizens and other stakeholders; recognizing that vested interests that tend to pull health systems in different directions raise the premium on leadership and vision and on sustained learning to do better.” - WHO World Health Report 20088 Our health is intimately connected to the social and physical contexts in which we live. Whereas just twenty years ago our understanding of health was still skewed heavily toward bio-medical concerns and questions of individual lifestyle and behaviour, the weight of global evidence has since shifted. We now know that social factors like access to education, early childhood supports, housing, employment, adequate income, and freedom from discrimination on the basis of race, gender or other characteristics are crucial to health outcomes. The impact of these social determinants of health is substantiated by a massive body of research from jurisdictions around the world.9 It is the unequal distribution of resources and opportunities within these social determinants of health that underlies pervasive disparities in health outcomes. Within each society, social determinants of health combine in different ways to produce disparities in health status among individuals and groups. That is why they are often referred to as ―the causes of causes‖. So while the lion‘s share of media attention and public policy debate continues to surround issues like access to physicians and the importance of diet — both of which are important — the majority of root causes for illness remain largely unaddressed. A large number of these resulting disparities in health are imminently preventable, either through changes in public policy (e.g., access to affordable housing and social security programs) or reforms to the way health services are delivered. 5

Health equity explicitly recognizes that because many disparities in health are rooted in social inequality and inequity and causes that can be prevented, broad strategies are needed to mitigate and reverse these determinants. In the first place, this means working to reduce and eliminate ―unfair differences‖ in access to opportunities and resources for health. In the area of health care and other social services, however, programs and resources must also be targeted towards health disadvantaged individuals and groups. So, health equity entails both a prospective mission to prevent inequity, by focusing on development of just and healthy public policy. And it also entails a retrospective dimension – not dissimilar to the spirit of ‗restorative justice‘ – where the goal is to address past inequity, in this case as manifest through health disparities, or simply put, poorer health. Health disparities have been identified in jurisdictions the world over, with irrefutable evidence making clear that factors such as poverty, inadequate housing, racism and other social inequities cause some individuals and groups to be or become less healthy than others.10 In Canada, a variety of recent studies have increased our understanding of health inequities in the Canadian context. According to Canada‘s Chief Medical Officer of Health, ―while most Canadians enjoy good to excellent health, as a result of social, economic and environmental factors, some Canadians are less healthy than others".11 The Medical Officers of Health from Canada‘s 18 largest cities have also highlighted ―persistent health inequities across the socio-economic spectrum in urban Canada‖.12 We know, for instance, that:  Hospitalization for chronic obstructive pulmonary disease (COPD) among groups with low socio-economic status (SES) in Canada‘s cities is 2.7 times higher than among groups with high SES, and 3.4 times higher among lower SES groups for substance- related issues;13  Across Canada, lower income is associated with increased prevalence of poor self-rated health, various chronic conditions and other illnesses. For instance 25-26% of low- income men and women report their health as only ―fair‖ or ―poor‖, compared to just 7- 8% of men and women in the high-income bracket14. Women, Aboriginal peoples and other racialized groups are disproportionately represented among those in the low- income bracket;15,16  There are consistent differentials in life expectancy by income: men in Canada at the top income decile live 7.4 years longer than those in the bottom income decile, and this same income differential accounts for a 4.5 year life expectancy difference in women; 17  Immigrant parents are almost twice as likely to report their children in poorer health compared to parents born in Canada;18  Diabetes rates among Aboriginal populations in Canada are 3-5 times higher than the general population, with increasingly alarming rates of childhood diabetes. 19 6

These are just a few snapshots of persistent health inequities across Canada, and the underlying social determinants that shape them. The need for increased attention to social causes of illness does not diminish the importance of responses and action within the health system, nor our need to attend to bio-medical dimensions of health and health care. The persistence of these health inequities and the impact of social determinants on health do, however, place health system and bio-medical approaches to health in proper perspective. They also underscore the need for us to identify practical strategies to foster links between the health system and the constellation of social determinants that affect our health. One of the greatest opportunities to accomplish just that is through primary health care. PHC is crucial because it is a key entry point to the health care system for most people; PHC is closer to the actual socio-economic conditions that affect health than many other parts of the health system; it can be easier to connect to relevant social services outside of the health system proper; and there can be a natural overlap between primary clinical practice areas and health promotion and community development practice areas. In order for PHC to be effectively tapped as a driver for health equity and improved population health, it is imperative that PHC reform be grounded in a health equity approach. This is unlikely to occur unless PHC reform is appreciated as a shared social shift, as well as a health services shift. Action Pillar #1: Establishing a civic framework for primary health care reform, grounded in health equity Due to the deep inter-connections between social determinants of health, health services, and our health, it is imperative for action on PHC reform to be undertaken as a broad social shift. Ultimately, we cannot improve our health or our delivery of PHC services unless they are connected within a virtuous circle of civic, political and health system engagement. At the level of actual PHC services and programs it is ‗relatively‘ easy to describe the sort of shifts in perspective and approach that would characterize an effectively reformed PHC system. Table 1 (on the following page)20, for instance, outlines what this positive shift toward ―Comprehensive PHC‖ (the term employed by its authors) would look like. 7

Table 1: A systemic comparison of primary health care approaches COMPREHENSIVE SELECTIVE MEDICAL PHC PHC MODEL View of health Positive wellbeing Absence of disease Absence of disease Locus of control Communities and Health professionals Medical practitioners over health individuals Health through equity Disease eradication Health through medical Major focus and community through medical interventions empowerment interventions Health care Multidisciplinary Doctors plus other Doctors providers teams health professionals Strategies for Multi-sectoral First level health system Medical interventions health collaboration interventions Such a shift would entail activism and collaboration across government ministries, in pursuit of a shared population health agenda, rather than simply increased spending from ministries of health. And it would entail renewed public dialogue about the actual causes of health and illness, rather than simply wait times and other perceived gaps within our health care services. The ‗invisible‘ element at play within Table 1, therefore, is renewed civic and political engagement. And, the persistent challenge of health inequities in Canada — despite our relative success in providing access to health care — underscores the urgent need for such engagement around the actual make-up of those services and the deeper social causes of our health and illness in general. There are already innovative examples of the type of comprehensive policy frameworks and relationships that are needed, and which may be tapped and adapted. In Saskatchewan, for example, the provincial government took a bold step, in 1994, by establishing the Saskatchewan Human Services Integration Forum. The forum is comprised of deputy ministers from eleven ministries and secretariats, and is designed to help the province achieve specific health and social equity objectives by promoting and facilitating inter-ministerial collaboration and integrated planning and service delivery. The forum also links to nine regional inter-sectoral committees whose membership includes organizations like school boards, band councils, police departments and housing authorities. 8

Working together, these forums provide overall coordination to provincial initiatives designed to improve key dimensions of population health and well-being. 21 In Ontario, the provincial government established a Cabinet level committee in 2007, whose mandate was to develop and implement a provincial poverty reduction strategy. The committee, led by eleven ministers and parliamentary assistant MPPs, engaged civil society groups and collaborated across ministry silos to determine key directions for poverty reduction province-wide. This lead to legislation that commits the province to ongoing poverty reduction measures. And, it helped galvanize civil society groups in a renewed push to reduce poverty in Ontario; a broad movement which continues to push forward to reduce poverty in Ontario by 25% over the next five years.22 At a federal level, while the Canadian government remains woefully silent on the need for action to address the root causes of illness and inequity in Canada, there has been promising movement within the Canadian Senate. In 2009, the Senate, under the leadership of Senators Art Eggleton and Hugh Segal released In From the Margins: A Call to Action on Poverty, Housing and Homelessness, which includes recommendations to mitigate root causes of inequity across Canada, based on two years of research and public consultation.23 Also in 2009, the Senate Sub-Committee on Population Health released a major report on how governments and other stakeholders can address the social determinants of health and reduce health disparities.24 Such examples demonstrate that where there is political will, government can effectively coordinate to make population health and welfare a shared political responsibility. As part of a civic framework for PHC renewal grounded in health equity, such inter-sectoral collaboration must become common to all provincial and federal governments, with public policy makers attuning their individual and collective efforts to the potential health impact of policy decisions, whether in the area of education, housing, employment, agriculture, transportation or other. But government policy coordination is only one part of building health equity into policy and social change. Civic engagement, through meaningful public discourse is the other half. With respect to health equity-based reform of PHC, progressive civil society groups, health and social service stakeholders and news media must each play an increased role engaging the public in an ongoing conversation about our health, the root causes of illness, and the need for PHC service reforms. Ideally, such a charge toward public engagement would involve leadership from a responsible and responsive government, as a reflection of its unique capacity as steward of public resources and the public good. Absent such leadership, however, this responsibility falls to civil society groups and news media — those, at least, which can be coaxed away from the status quo. Unfortunately, news media remain largely, if not almost exclusively focused on a diet of divisive, hot-button issues such as surgical wait times, and narrow ―lifestyle‖ columns 9

that neglect the social causes of health and illness—in other words, the 90 percent of the health/illness ―iceberg‖. Evidence of this troubling incompetency on the part of news media was perhaps most evident in the aftermath of the Romanow Commission Report in 2002. Health policy professor Raisa Deber noted, in 2005, that, despite a wealth of important findings coming out of the Romanow Commission: Sadly, virtually all of the media attention has been focused on a small part of its message: the need for more doctors and nurses, and for faster implementation of electronic health records. Scant attention has been paid to the report‘s rather unfashionable focus on the need to ‗reduce the number 25 of Canadians who lead disadvantaged lives devoid of opportunity or hope‘. Notable exceptions to this media bias do exist, and merit recognition. Still, these typically are fashioned into occasional ―special features‖ or special exposés, the Hamilton Spectator‘s excellent Code Red series on the determinants of health being a prominent example. It is imperative that such exceptions become the norm, and for the fifth estate to fulfill its role and responsibility in informing the public and galvanizing action around the priority causes of illness and health inequity among Canadians. The importance of an informed and engaged public cannot be under-estimated. The Honourable Monique Bégin has argued, with specific reference to her own experience across decades of public service, that when policy makers ask the ―do I see a demand?‖ question26 -- in this instance, referring to Canadians‘ demand for PHC reform – the answer must clearly be ―yes‖. This underscores the importance of persistent social advocacy to move health equity and primary health care reform forward. Without pressure from the ground up, as has typically been the case surrounding hot- button issues such as access to physicians or surgical wait-times, any movement in favour of a holistic approach to health, and health equity-based PHC reform is likely to gain traction very slowly, if at all. While this longer-term project is huge, there is a myriad of ways in which committed civil society groups, health sector organizations and others can take small steps to re-focus attention on the social causes of health and illness, and to help mobilize news media as allies in representing our shared health interests. As to the Canadian public‘s desire to actually become further engaged, and particularly regarding PHC, a concluding note from the Romanow Commission Final Report might give us further cause for optimism: Canadians too, appear to support primary health care change. While they may not understand all the details of what primary health care means, recurrent themes in the consultations and opinion polls conducted by the Commission underscore the importance they place on health promotion and prevention, their hope for strong and accessible primary health care services, and their desire to have a long-lasting and trusting relationship with a health care professional… …For health care, it is remarkable to see such a high degree of agreement. The issue, then, is not whether primary health care is the right approach to take but, rather, removing the obstacles and actually making it happen.27 10

Action Pillar #2: Reform of Primary Health Care services and programs The importance of primary health care reform is not news to Canadian governments nor health system stakeholders. The Canadian federal government invested $800 million, from 2000-2006, for instance, in a federal-provincial-territorial Primary Health Care Transition Fund. Its goal was ―…fundamental and sustainable change to the organization, funding, and delivery of primary health care services that will result in improved access, accountability and integration of services‖.28 However, these efforts were not sustained beyond this period. Nor were they guided by recognition of the deeper, systemic connection between PHC services and social factors and health disparities -- the sort of connection that must be at the core of effective PHC reform. Instead, the Fund‘s pilot projects and reforms focused mainly on interventions aimed at moving PHC services from the ―Medical Model‖ toward the ―Selective PHC‖ model, as outlined in Table 1 (above). The Fund‘s short duration, and limited attention to health equity as a central premise, meant that it fell far short of the sort of shifts in attitude toward health and health care that are essential to entrenching an effective, health equity-based PHC system. Ultimately, the potential of the Primary Health Care Transition Fund in Canada slowly dwindled as it became yet another PHC reform initiative with ―targeted, short-term objectives driven by short political cycles and the search for quick outcomes‖.29 Nevertheless, the Fund did demonstrate that a large-scale, collaborative approach to PHC reform at federal and provincial levels is possible. At the level of PHC services reform, a health equity approach requires not only identifying groups and communities that are faring more poorly, but committing to systemic service reforms so that services are better attuned to and can address the complex social factors that affect health, especially for those most disadvantaged groups. It requires us to recognize, as part of this dynamic (and as borne out in significant research), that while Canadians overall may have relatively good access to primary care services, many groups have much poorer access, including lack of access to the right sorts of services. Inequitable access to primary health care has been reported based on language, gender, race, sexual orientation, socio-economic status and the inter-section of these and other factors. The POWER Study in Ontario, for example, recently confirmed again that while access to primary health care overall is quite high, due to our universal system, there are major gaps in access and quality for different population groups. It noted, for instance, that: • The % of recent immigrants who were satisfied with being able to get a routine check up and with care from their doctor was about 1/3 less than for Canadian-born individuals and immigrants who have been in Canada for 10 years or more; 11

• The % of people who speak neither English nor French as their primary language at home, were also satisfied with access and care from their doctor for an urgent problem about 1/3 less than those who speak English or French at home; • 84% of women and 88% of men living in the highest income neighbourhoods reported having ―no difficulties‖ in making an urgent primary care appointment versus just 76 % of women and 77% of men living in the lowest income neighbourhoods; • Nearly one in four Aboriginal women (24%) reported unmet health care needs, as compared to 14% of White women and 10% of East and Southeast Asian women.30 And so, ―access to care‖ and ―appropriateness of care‖ factor in as key variables determining whether primary health care services either contribute to, or mitigate health inequity. Questions such as ―do Canadians have adequate access to physicians?‖ and ―are Canadians being adequately screened for high priority medical concerns?‖ must therefore be expanded to better reflect concerns around who has access, as well as the broader role of ―primary health care‖ rather than just specific health care providers, or medical procedures. This would entail asking questions such as:  Do Canadians have adequate and appropriate access to primary health care?  Which Canadians have access, and do they have access to the right type of care, at the right time, from the right providers?  Do services treat the individual as a whole person, including attention to the impact of social factors that may be affecting them, such as low-income, housing or racialization?  Are there appropriate referral protocol and networks in place to ensure that all primary clinical care providers refer clients to the complementary support services they require?  Are members of the community being involved in the planning of services within their communities?; and, in determining priorities?; and, is their feedback regarding services regularly sought? In light of this shift, governments and health system stakeholders must take steps to reform PHC services and programs as follows. Improve overall integration of primary clinical care with health promotion and community development programs The factors which either engender or inhibit health, reach far beyond the individual. As such, routine supports to foster health must move beyond the traditional clinical 12

investigation, incorporating health promotion into the scope of clinical services, as well as linking those services to programs which support individuals, groups and communities at large to become healthier. In the case of a chronic disease such as diabetes, for example, this shift would include an integration of nutritional counseling into the clinical setting, as well as delivery of group self-management classes in cases where the prevalence of diabetes is high. And in situations where community-level barriers to health are related to the incidence and prevalence of diabetes — for instance, low-income or poverty, un-safe environment for exercise, and other factors — these clinical and counseling services must be deliberately linked to coordinated advocacy efforts that address access to affordable foods, community safety and other social factors. This integrated approach may take place under the single roof of a comprehensive health centre, such as a Community Health Centre (CHC), or through development of appropriate partnerships in the community between clinical primary care services and other complementary services. Since the scope of services that can and should be integrated within a single, organizational structure may vary, it is critical to explore a variety of innovative strategies to achieve service integration. One notable and highly-promising example is the ―hub model‖ which has been introduced in Toronto, as a partnership between the Government of Ontario, the United Way of Toronto and participating agencies. Through this model, diverse health and social service agencies are planned and funded to co- locate in a central hub location, providing centralized access; increased opportunities for important cross-agency referrals; improved efficiencies in capital and infrastructure spending; and a move toward collaboration across levels of government and sectors within government. The hub model is but one example of how services may be better integrated. However organized, the integration of primary clinical care with health promotion and community development programs must be the responsibility of all primary care providers and organizations. This means that it must no less be the responsibility of a private-practice family physician to coordinate his/her services with health promotion and community development efforts than it is a more complex, health agency such as a Community Health Centre. Provincial governments, with support from the federal government, should undertake development of best practices and protocol for such care-service-program integration, including a move toward integration beyond health services, to include key social services. And, this integration should be made a requirement of all service and payment agreements entered into between government, health authorities and PHC service providers, including physician practices and other clinical practices. 13

Implement an appropriate mix of PHC delivery models to meet diverse population and community needs Within each province and territory, primary health care must be planned and funded as a coordinated system. This requires development of methods to ensure that available health human resources are distributed as broadly as possible, while ensuring that those services range in scope and comprehensiveness to meet the needs of diverse communities. The typical family physician practice, for instance, is not structured to provide the necessary supports required for more complex care, even at the level of immediate medical and behavioural concerns. Supports such as physiotherapy, group support programs (e.g., for diabetes), nutritional counseling, and cultural interpretation are rarely available to clients in need. Some of these supports may be (and should be) achieved through outside referrals. However, currently, there is little guarantee across provincial health systems that these referrals will be properly coordinated, culturally appropriate, or even physically accessible to those who need them. More problematic still, even an integrated, clinical care team, such as Ontario‘s new family health teams or Nova Scotia‘s primary health care teams, cannot themselves adequately address the social factors that are at the root of many health concerns for individuals, groups many communities at-large. The individual ailment, such as diabetes, may receive attention. Meanwhile, the ―90 percent of the iceberg‖ relating to the ailment — inability to afford nutritious food, unstable housing, and unavailability of safe spaces for exercise, for example — go unaddressed. This is not to question the commitment or skills of medical and other clinical practitioners, the vast majority of whom are tremendously committed to the care of their clients. Instead, it is to suggest that in addition to team-based clinical care, even more robust PHC responses are required within the coordinated provincial PHC system. A health equity approach to PHC reform demands that we ensure access to a mixture of delivery models, including a Comprehensive PHC model, such as Community Health Centres (CHCs). This comprehensive model is essential for groups and communities that experience increased health inequities and are affected more deeply by social factors that pose barriers to health, such as low-income, inadequate housing and other forms of exclusion. From a health equity perspective, planning an appropriate provincial mix of models, including CHCs that coordinate the wider range of clinical, health promotion, community development and other programs under a single roof, is essential to improving the health of the population. One recent Ontario study (funded by the Primary Health Care Transition Fund, in fact) argued that in a comparison of primary health care models, ―findings suggest that a 14

number of organizational models are required to account for variations in socio- demographic contexts and patient and provider needs‖.31 Those populations facing the most significant health disparities are also those most likely to fall between the gaps of traditional physician-driven PHC services. Therefore, a health equity approach to PHC reform requires a very deliberate commitment and plan not only to increase CHC and comparable services across Canada, and in each province, but to target this expansion first to the most under-served and marginalized communities.32 There has been some success in implementing the CHC model across Canada for those in “The reason we’re expanding need. However, these successes are mainly CHCs so dramatically in limited to Quebec and Ontario, with notable local Ontario is simple: they work. exceptions in other provinces, Saskatoon, They’re one of the most Winnipeg and Halifax being a few examples. effective tools we have to In Quebec, the provincial government set upon a address health issues – and plan beginning in the early 1970s to ensure that by health issues, we don’t just all residents who needed them, could access mean treating people when CHC-type services – called CLSCs, in Quebec. they’re sick, we mean the The plan, whose initial target was to implement entire range of factors that one CLSC per 30,000 persons in urban areas contribute to healthy lives and and per 10,000 in rural settings, was gradually unfolded throughout the 1970s and 1980s, as healthy communities.” part of an ambitious health and social service reform initiative guided by an integrated Ministry Then Ontario Minister of Health and of Health and Social Services.33 As a result, Long-Term Care, the Hon. George Quebec has become the province which has Smitherman (November 2005) come closest to completing a provincial network of CHCs. While the total number of CLSCs has still not reached the threshold initially envisioned (originally a total of 200 CLSCs were planned, based on 1970 population figures 34), successive provincial governments continued to expand the CLSC network. Today, 149 CLSCs cover the entire area of Quebec.35 At the same time, a cautionary tale must be issued about more recent ―regression‖ in Quebec, despite the fact that CLSCs remain a bedrock of the provincial health system. While CLSCs remain key primary health care agencies, their role and potential impact have been imperiled, over the past decade, due to a seismic shift in Quebec‘s health system toward ―rationalization‖ of services. This has included the amalgamation of local health care organization Boards (including the Boards of CLSCs) into local mega- Boards, and expanding the ‗catchment‘ regions of health care agencies. 15

The impact of these politically-driven changes has been to jeopardize the capacity of agencies, such as CLSCs, to remain connected to local community members and realities, and to engage them in planning and direction of services. This community engagement is a critical health equity measure described in greater detail in the next section of this paper. In fact, through increasingly large planning and service areas (meaning, in some cases that an individual CLSC has become responsible for a population catchment size of 90,000 people instead of the original urban target of 30,000) the very texture of ‗community‘, which once was at the core of the CLSC mission and Quebec identity around primary health care, is being slowly eroded. Serious apprehensions, therefore, now predominate in Quebec, where once the province‘s CLSCs were the envy and a subject of study for health planners from around the world. Fortunately, the picture has been somewhat more encouraging in Ontario over the past several years, and it would be fair to say that Ontario has now taken over ―the lead‖ from Quebec in espousing a vision for, and implementing the Comprehensive PHC model. Significant progress has been made in Ontario in expanding an appropriate mix of PHC models, following the 2004 decision to initiate the largest ever expansion of CHCs in the province‘s history. Nearly 100 CHCs and similar Aboriginal Health Access Centres (AHACs) now dot the province. Unfortunately, Ontario and Quebec remain Canada‘s exceptions in terms of provincial attempts to implement a network of CHCs, and still, the Ontario and Quebec CHC/CLSC networks remain incomplete. While provincial governments can and must take initiative to mount appropriate CHC access strategies within their jurisdictions, the federal government also has the potential to wield important influence —through the Canada Health Transfer and other policy and funding mechanisms — to catalyze this movement in every province and territory. We argue, moreover, that the persistence of health inequities, now a veritable national crisis, particularly for various segments of the Canadian population, constitute an imperative for federal action around PHC reform, with CHCs playing a central role, Federal leadership could include infrastructure funding, for example, to ensure that all provinces and territories are able to develop adequate access to CHCs for those facing deep health disparities. An example of such federal leadership already exists, and it comes from a place that might surprise most Canadians. In a rare reversal of health care progress and fortunes, Canadians actually need look no further than the United States for an example of national leadership on primary health care reform and CHCs. In the US, President Barack Obama and the US Congress have recently invested roughly $13 billion, through the American Recovery and Reinvestment Act 2009 and the 2010 health care reform act, to expand the operations of the nation‘s federal CHC program from 2009 through 201536,37. This funding will double the number of Americans 16

served by CHCs throughout the US, building on a previous doubling of the US national CHC network by the Bush administration and Congress. From 2000-2008, President George W. Bush opened or expanded 1,297 new CHCs nation-wide, increasing to 20 million the number of Americans served by CHCs. The consecutive doubling of CHCs across the US by Presidents Bush and Obama, supported overwhelmingly by the US Congress, demonstrate that there is clear, bi- partisan recognition and support for CHCs as a key health care solution in the United States. By the time Obama Administration investments are complete, it is estimated that over 40 million Americans (more than 1 in 10 Americans) will receive CHC-based care throughout the United States, through a national network of over 2,500 CHCs. Primary health care and other system drivers Investments such as these are not just critical to ensuring appropriate care and support for individuals and groups affected by persistent heath inequities. Three decades of international and Canadian research show that access to CHCs helps reduce major health system costs. In the US, for instance, CHCs have saved 30% per person compared to fee-for-service physician care, adding up to a saving of $3 billion annually for Medicaid due to reduced specialty care referrals and fewer hospital admissions.38 In one of the most advanced comparisons of models, in the State of Michigan, a 2006 University of Michigan study showed that across nearly 172,000 CHC clients, CHCs saved over $44 per client compared to fee-for-service practices. This saved $33.5 million in Medicaid costs to the State of Michigan, and $43.5 million in Medicaid costs to the federal government.39 In Canada, CHCs have demonstrated savings to the overall health system in a diverse range of urban, rural, affluent and lower-income populations, and in those with significant access barriers. For instance, CHCs in Prince Albert and Saskatoon have shown per person savings of 13% and 17%, respectively40. With federal and provincial leadership, implementation of a mix of models, including commitment to more CHCs as a key component of health equity-based reform, would have also have an immediate impact on hospital costs. In the US, a wide range of studies over the past three decades show that access to CHC primary health care reduces hospital stays between 13 and 38%.41, 42, 43, 44, 45, 46, 47, 48 In Canada, cost savings and a de-burdening of hospital services would likely be greatest in the area of ambulatory care sensitive conditions (ACSC) and emergency department (ED) visits. ACSC are conditions, including angina, asthma, chronic obstructive pulmonary disease (COPD), congestive heart disease, diabetes, epilepsy and hypertension, where appropriate primary health care in the community can have a major impact in preventing or reducing the need for hospital admission, as well as other hefty health care costs. 17

According to recent data from the Canadian Institute for Health Information, these conditions cost the Canadian health system over $801 million per year in avoidable hospitalization costs.49,50 The ACSC hospitalization rate among Canada‘s lowest-income neighbourhoods — those which are most in need of CHCs — is more than twice as high (521 per 100,000 population) as the rate in the highest-income neighbourhoods (234 per 100,000 population).51 By increasing appropriate care and support to Canadians, CHCs have the potential to dramatically reduce ACSC hospitalization costs in provinces and territories nationwide and to reduce disparities. In the area of emergency department (ED) visits, studies in many countries have demonstrated high rates of avoidable hospital ED visits resulting from the lack of access to primary health care options. In the US, wasted expenditures of avoidable ED visits cost federal and state governments close to $18.5 billion per year.52 While a similar and precise figure has not been calculated in Canada, federal and provincial commitments to CHC access would play an important role in helping prevent avoidable ED visits, and help reduce backlogs experienced by all Canadians. The capacity of CHCs to provide inter-professional triage, same-day appointments, walk-in services, and extended hours of service (on-call and 24/7 service) enable them to provide appropriate alternatives to non-urgent ED visits, and in ways that are difficult or impossible for other models of primary care (e.g., fee-for-service physician care). Expand inter-professional Primary Health Care Significant evidence shows that team-based collaboration among physicians, nurses, dietitians, social workers and other health providers improves comprehensiveness and quality of primary health care services – especially for those facing complex care needs. It also maximizes scarce health human resources, and helps to reduce the need for costlier acute and long-term care services.53 A recent pan-Canadian study by Statistics Canada, for example, found that individuals who have access to a primary health care team are more likely to receive health promotion and disease prevention, particularly those who have chronic conditions. And they are also more likely to report receiving a higher quality of health care.54 Similar results have been found at provincial level as well. A comparison of PHC models in Ontario, for instance, found that an inter-professional model of care scored significantly higher than individual physician or physician group practices in comprehensiveness of PHC services. The inter-professional care model also achieved notably better results in the areas of disease prevention, health promotion and chronic disease management.55 18

In Québec as well, a major review of PHC organizations found that ―integration of services and inter-professional collaboration, essential components of integration, appear to be associated with positive effects respecting accessibility, continuity, and comprehensiveness. This is especially found among more vulnerable clienteles presenting with multiple, complex problems‖. 56 In addition to collaborative team-based PHC delivery, research has also found that the way providers are compensated also has an impact on quality and comprehensive of care for persons facing significant barriers to health and complex care needs. Important evidence of this stems from an Ontario study that followed groups of physicians compensated through either fee-for-service payments, a ‗capitation‘ payment model or paid by salary. Among the complex needs clients — in this case, persons with disabilities — the study found that physicians who chose to be part of a salary practice, rather than a fee-for- service or capitation practice:  had offices that were more accessible to people with disabilities;  made more accommodations for the needs of their disabled patients;  were more likely to work with other doctors;  were more likely to offer other health services on-site;  scored higher on quality of care for hypertension, diabetes and urinary tract infections; and  scored higher on preventive health care.57 Increased inter-professional PHC practice is important to improve accessibility, quality and responsiveness of care in general. At the same time, this shift toward increased interprofessional PHC is also important to all Canadians from the perspective of systemic cost controls. Across Canada, the costs of physician fees for service (FFS) have grown steadily over the past decade, from $8.7 billion in 2000-2001 to just under $11 billion in 2005-2006. Out of this, FFS payments to family physicians now cost Canada $4.9 billion per year.58 Some of these rising costs are attributable to population growth and complexities of care. However, savings can be realized by addressing inefficient use of existing resources on FFS physician services, many of which could be provided more cost- effectively by other qualified providers such as nurses or nurse practitioners. In 2005- 2006 alone, family physicians billed provincial health systems for over 17.5 million ―special‖ and ―miscellaneous‖ services — immunizations, pap smears, and other services — many of which could be provided more cost-effectively by other providers, in a PHC team setting.59 By enlisting the coordinated services of different providers in the PHC team setting, family physicians are ―freed up‖ to actually focus their unique skills and energies on the areas and scope of care for which they alone are qualified. Increasing access to inter-professional PHC, and thereby freeing up physician time for more appropriate care, will ultimately enable more Canadians to access physician services when they are needed. The key is to make sure that physician services are 19

situated within a systemic approach to PHC where everyone gets ―the right type of care, in the right place, at the right time‖. Unfortunately, fewer than 40% of Canadians report having access to the bare minimum of inter-professional PHC — defined as access to at least one other provider in addition to a physician (e.g., nurse, dietitian, etc) at the site of their regular PHC visits.60 Federal and provincial governments can and must play a leadership role in expanding access to inter-professional PHC by:  Increasing funding for models of PHC that employ a collaborative, team-based approach;  Providing resources and establishing frameworks for the training of physicians, nurses and other health providers in team-based practice during the course of educational and residency placements;  Developing provincial payment models, agreements and protocol for all health providers practicing in team-based settings that appropriately respect the work done by each member of the team, and which optimize care for persons experiencing health inequities and complex care needs;  Supporting the ongoing assessment of best practices in team-based PHC and implementation of a continuous quality improvement approach Steps such as these, however, are not solely the responsibility of government. Academic training institutions, health professional associations, and health organizations must all collaborate to foster a movement toward team-based, inter- professional PHC. This includes working collectively to dispel a common myth that PHC services provided by practitioners other than physicians are ‗second class‘. 61 Improve and expand community engagement in planning and delivery of PHC services and programs A growing body of research indicates that community engagement increases responsiveness of services; increases accountability and transparency; helps reduce avoidable health system costs; and improves health outcomes. This is because when people are involved in planning their own community‘s health care needs and resources, they create strong, vibrant organizations able to deliver the most relevant and the most sustainable services.62 These factors are especially relevant for groups and communities that experience increased health inequities. While clinical care providers, health promotion staff and community development workers may have the expertise and skills to implement care and services, community members know best what the barriers to health and access to services look and feel like. 20

A pan-Canadian study of CHCs, for example, found that ―citizen participation‖ in CHC decision making, through community-governance boards, led to improved programs and services. The broader range of programs and services also met the needs of the community. And community boards provided a strong link to larger local, provincial and national institutions and networks, ensuring that clients faced less risk of experiencing gaps in appropriate care and support.63 New Zealand research compared community-governed, non-profit primary care practices with for-profit primary care practices and found remarkable differences between these two types of primary health care organizations. Researchers suggested that these differences had a close association with their organizational governance.64 Community governed non-profits were more likely to have quality management policies and to carry out local service planning and community needs assessments. They also had policies and practices in place that reduced financial and cultural barriers to access of services.65 The correlation between community engagement and health outcomes is an area warranting vastly more study. Nonetheless, existing evidence suggests that not only does community engagement result in greater responsiveness of services and increased client-centred advocacy, there is also a correlation with improved health outcomes.66,67 Actual community governance of PHC services is the fullest expression of community engagement. But it is not the only form of engagement. Community engagement occurs across a spectrum, ranging from local consultation, through to community involvement in specific programs, and leading more and more progressively toward the actual participation of community members in governance. While it is ideal for PHC providers and organizations to strive toward increased community participation in planning of PHC services, a flexible approach is important to accommodate local realities. At a minimum, it is recommended that all PHC providers, from CHCs to independent, family physician groups should have:  a defined, publicly-accessible community engagement strategy;  a formal community engagement entity, which could be a community advisory panel, a community reference group or a community-governed Board of Directors;  a client satisfaction survey which is routinely distributed, with results presented back to community advisory panels, Boards of Directors and regional health authorities. 21

Improve collection and quality of health information to better inform action on health inequities, particularly at the level of primary health care Ultimately, PHC reform, including an inter-sectoral approach to tackling the impact of negative social determinants of health cannot be optimized if it is not informed by rich data and collection of robust health information. Unfortunately, information collected within the health system and at PHC level continues to be focused far too narrowly on clinical process indicators, and seldom is any of this information correlated to social, economic and other demographic factors that bear relevance to the health status of diverse groups and communities. At the level of process indicators, provincial health systems continue to invest vast resources in measurement of service performance (particularly for physicians), with these performance measures — diagnostic tests and numbers of clients seen, for example — usually tied to the provider‘s fee and incentive payment schedule. Rarely, if ever, are PHC providers and organizations funded to collect data related to health promotion or community development programs and their impact on individuals, groups or communities at large. Nor are there publicly funded health information programs designed to help determine to what extent health disparities are experienced across gender, race, socio-economic levels or other important factors. Instead, our limited understanding of these specific issues results from community-based or academic research, funded through private research foundations, endowments or small, government programs. There is a tremendous need to systematize our collection of rich, dynamic data that more accurately reflect the dynamic factors that contribute to health and illness, as well as the various contributions of clinical, health promotion and community development services and programs. While this will require a long-term approach, there are numerous ways that provincial governments can make meaningful, incremental progress beginning immediately. These include working collaboratively with team-based clinical practices and CHCs to develop core sets of process indicators related to services beyond merely those attached to physician payment schedules. There is also a great deal of innovative, front-line primary health care across the country addressing the needs of health disadvantaged communities. These programs and services at Community Health Centres, other community-based agencies, hospitals, social services, and cross-sectoral collaborations have the potential to significantly ameliorate the health of those experiencing heath disparities, addressing the underlying foundations on a local level. 22

However, little systematic research has been done on the outcomes of such equity- driven service provision, the key ‗success factors‘ that underlie many of these innovative programs, and the policy and institutional frameworks needed to enable further, local innovation and equity-focused initiatives. Similarly, the great potential of this wealth of front-line innovation is not currently being realized because there are few ways to systematically share ‗best practices‘ and ‗lessons learned‘ among service providers. Governments need to support forums and infrastructures that enable us to systematically identify promising primary health care and related innovations, evaluate and assess their potential beyond their local circumstances, share information widely on lessons learned, and scale up promising initiatives where appropriate → all to create a permanent cycle and culture of front-line innovation around health equity. Committing to action, getting started It is unrealistic to suggest that somehow, overnight, Canada can move from a primary health care landscape dominated by fee-for-service physician practice to one more fully shared by inter-professional health care teams and Community Health Centres. Nevertheless, this is the direction we must head if we are to tackle health inequity and build a more effective, sustainable health system for future generations. Similarly, the integration of clinical services with broader health promotion and community development programming, and deeper civic engagement around our health as a shared social goal, are projects that require years and generations of effort, with commitment from successive waves of government. Several obstacles abound, let us be honest:  Provincial health insurance plans and planning entities are currently not structured for a quick and major infrastructure and operational shift toward inter- professional and CHC services;  Health organizations and regulated health professions remain far too entrenched in their health-sector specific and profession-specific silos;  Medical, nursing and other health professional training schools do not sufficiently prepare health care providers to practice within a dynamic team-based health system; and  General public and media discussion remains far too narrowly trained on hot- button issues like access to family physicians. Even if the political will and determination existed at federal and provincial government levels to massively overhaul PHC, these systemic barriers would pose significant 23

obstacles to rapid transformation. What is required therefore, is commitment to a strategically-planned, methodical, ‗long-haul‘ approach, with intervention on multiple fronts. This would include:  Beginning to train tomorrow‘s health professionals in collaborative, inter- professional practice;  Developing appropriate funding and planning models to facilitate inter- professional practice, and appropriately compensating health professionals working in existing team-based models;  Methodically scaling up the number of CHCs in each province, based on absorptive capacity considerations, and prioritizing access for those communities facing significant health inequities;  Developing inter-sectoral government commissions and committees to facilitate multi-sector collaboration on health, with short, intermediate and long-term targets;  Establishing better links between provincial health systems and municipal public health programs, ensuring that municipalities are more integrated with the provincial PHC system;  Developing practice guidelines and establishing basic community engagement requirements for all PHC organizations, including family physicians and group physician practices;  Investing resources federally and provincially to begin engaging the Canadian public in an ongoing conversation regarding the transformation of our PHC approach through national and provincial public awareness campaigns. In other words, we must ―think big, but we must get going‖68. Long-term commitment is necessary, and for this, it is critical that we employ a binding, Canadian vision – such as the vision of the Second Stage of Medicare – to keep us focused on that shared, longer- term goal. Let us get started right away, refusing to let perfection be the enemy of the good. We must build on what we already know about what fuels health disparities, and the strategies that have proven effective in reducing them. 24

Primary Health Care in Canada Endnotes 1 World Health Organization (WHO). World Health Report 2008: Primary Health Care - Now More Than Ever. Geneva, 2008. 2 World Health Organization (WHO). Resolution of the 62nd World Health Assembly: Primary health care, including health system strengthening. Geneva, May 2009. 3 A comprehensive health equity strategy, for instance, has been developed by Bob Gardner, focused on the Local Health Integration Network level (Ontario‘s ―regional health authorities‖). It can be found at: http://www.torontocentrallhin.on.ca/uploadedFiles/Home_Page/Report_and_Publications/Health%20Equ ity%20Discussion%20Paper%20v1.0.pdf 4 Starfield B. ―State of the Art in Research on Equity in Health‖. Journal of Health Politics, Policy and Law, Vol. 31, No. 1, February 2006. p. 21 5 For a more detailed account and resources focused on the Second Stage of Medicare, visit: www.wellesleyinstitute.com/policy-fields/healthcare-reform/health-reform-through-an-equity- lens/second-stage-of-medicare . 6 Also, see: Medicare: Facts, Myths, Problems and Promise. Ed by Bruce Campbell and Greg Marchildon. James Lorrimer and Co., 2007; and, Rachlis M. Prescription for Excellence: How Innovation is Saving Canada’s Health Care System. Harper Collins, 2004. 7 Honourable Roy Romanow. ―Canada‘s Shared Destiny and the Future of Medicare‖, keynote address to the Change Foundation AGM. June 4, 2007. Also, as quoted in ―Ontario‘s Community Health Centres: Every One Matters‖, video of the Association of Ontario Health Centres (AOHC), 2010. Available at www.ontariochc.ca 8 World Health Organization (WHO). World Health Report 2008: Primary Health Care - Now More Than Ever. Geneva 2008. 9 World Health Organization (WHO). Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Op cite. 10 Ibid 11 Public Health Agency of Canada. ―Canada‘s Chief Public Health Officer Targets Health Inequalities in First Annual Report‖. Press Release. Op cite. 12 Urban Public Health Network (UPHN). ―Medical Officers of Health Call for Closing the Health Gap in Canada's Large Cities‖. Press Release. Accessed at: www.uphn.ca/doc/public/UPHNNewsRelease_20081124.pdf 13 Canadian Institute for Health Information (CIHI), Reducing Gaps in Health: A Focus on Socio-Economic Status in Urban Canada. Ottawa, 2008. p. viii. 14 Canadian Community Health Survey (Cycle 3.1), 2006. 26

Primary Health Care in Canada 15 Canadian Institute for Health Information (CIHI), Reducing Gaps in Health: A Focus on Socio-Economic Status in Urban Canada. Ottawa, 2008. p.13 16 Colour of Poverty Campaign. Fact Sheet Understanding the Racialization of Poverty in Ontario In Health & Well-being. Accessed at: http://cop.openconcept.ca/sites/colourofpoverty.ca/files/FactSheet_4_Health.pdf 17 Health Reports. Statistics Canada. December, 2009. 18 McKeown D. Impact of Poverty on the Health of Children from Racialized Groups. Toronto Board of Health briefing. April 10, 2007. 19 Health Canada. First Nations, Inuit and Aboriginal Health: Diabetes. Accessed at: www.hcsc.gc.ca/fniah-spnia/diseases-maladies/diabete/index-eng.php 20 Rogers W et al. Primary health care: a scoping report. National Information Service, Department of General Practice. Flinders University. 2000 21 Horsman H. The Human Services Integration Forum: Reviewing and Strengthening Interagency Collaboration and Integrated Service Delivery. Saskatchewan Ministry of Learning. October 2006. 22 More information regarding the Ontario 25 in 5 Network for Poverty Reduction may be found at http://25in5.ca/ 23 In From the Margins: A Call to Action on Poverty, Housing and Homelessness. The Standing Senate Committee on Social Affairs, Science and Technology; Report of the Subcommittee on Cities. The Honourable Art Eggleton P.C., Chair and the Honourable Hugh Segal, Deputy Chair. December 2009. 24 A Healthy Productive Canada: A Determinants of Health Approach. Senate of Canada Subcommittee on Population and Health. The Honourable Wilbert Joseph Keon, Chair and the Honourable Lucie Pépin, Deputy Chair. June 2009. Available at: http://www.parl.gc.ca/40/2/parlbus/commbus/senate/com-e/popu-e/rep-e/rephealth1jun09-e.pdf 25 Deber R. ―It‘s not about MD shortages, it‘s about working conditions‖. The Globe and Mail. Thursday, February 22, 2005. Fortunately, some exceptions to this status quo exist. For example, André Picard and Carol Goar, respectively from the Globe and Mail and Toronto Star, deserve mention as journalists who have often poked at the edges of deeper social issues and their particular connection to our health and well-being in Canada. 26 Bégin M. ―Do I See a Demand?‖..From ‗Medicare‘ to Health for All‖. Optimum Online – The Journal of Public Sector Management. Vol. 37, Issue 3, Oct 2007 27 Commission on the Future of Medicare in Canada. Building on Values: The Future of Health Care in Canada – Final Report. Ottawa, November 2002. 28 Health Council of Canada. Fixing the Foundation: An Update on Primary Health Care and Home Care Renewal in Canada. Ottawa. January 2008. p. 14 27

Primary Health Care in Canada 29 Dubois CA. Implementing Primary Health Care Reform: Strategies to Align Stakeholder Support. Summary of Discussions from a seminar organized by the Canadian Health Services Research Foundation. November 2004. 30 Bierman A. et al. ―Access to Health Care Services‖, chapter 7 of the POWER (Project for an Ontario Women‘s Health Evidence- Based Report) Study. March 2010. Available at: www.powerstudy.ca 31 Hogg W, et al. Comparison of Models of Primary Health Care in Ontario. University of Ottawa and Bruyère Continuing Care, 2005. 32 Starfield B. ―State of the Art in Research on Equity in Health‖. Op cite. 33 Gaumer B, et al. ―L'Histoire des CLSC au Québec: reflet des contradictions et des lutes à l'intérieur du Système‖. Ruptures, revue transdisciplinaire en santé. Vol 10, n 1, 2004, pp. 52-70. 34 Roy M. Les CLSC ce qu'il faut savoir. Éditions coopératives Albert Saint-Martin. Montreal, 1987. . 35 Canadian Alliance of Community Health Centre Associations (CACHCA). Community Health Centres: An Integrated Approach to Strengthening Communities, and Improving the Health and Wellbeing of Vulnerable Canadians and Their Families. Ottawa, May 2009. p.13 36 National Association of Community Health Centers (NACHC). NACHC Praises Historic Signing of Economic Stimulus Legislation. Press Release. Washington, DC. February 17, 2009. 37 Hawkins, D. ―Washington Byline: Into the End Zone!‖ Health Care Reform. Winter/Spring, 2010. Number 4. Washington, D.C. 38 Hawkins D et al. Health Centers and the States: Partnership Potential to Address the Fiscal Crisis. Journal of Ambulatory Care Management. Oct-Dec; 26(4): 285-95. 2003. 39 Michigan Primary Care Association. Direct State Funding of Community Health Centers. Legislative Priorities 2008. 40 Saskatchewan Health Policy Research and Management Services Branch, Community Clinic Study. July 1983 41 De Prez RD et al. The substitutability of outpatient primary care in rural community health centers for inpatient hospital care. Health Services Research. 1987. 22(2): 207-233 42 Fleming G et al. The municipal health services program: improving access to primary care without increasing expenditures. Medical Care. 1986. 24(7): 565-579. 43 Reeman HE et al.. Community health centers: an initiative of enduring utility. Milbank Memorial Fund Quarterly. 1982. 60(2): 245-267. 44 Gold M et al. Use of emergency room services by the population of a neighbourhood health center. Health Services Reports. 1974. 89(1): 65-70. 45 Moore G et al. Effect of a neighborhood health center no emergency room use. Medical Care. 1972. 10(3): 240-247. 28

Primary Health Care in Canada 46 Okada LM et al. Impact of community health centers and Medicaid on the use of health services. Public Health Reports. 1980. 95: 520-534. 47 Falik M, Needlesman J, Wells B, Korb J. Ambulatory Care Sensitive Hospitalizations and Emergency Visits: Experiences of Medicaid Patients Using Federally Qualified Health Centers. Medical Care. 2001. 39(6): 551-561. 48 Stacy NL. The experience and performance of community health centers under managed care. American Journal of Managed Care. 2000. 6(11): 1229-39. 49 CIHI. Health Indicators 2008. Ottawa, May 2008. 50 In 2006-2007, according to CIHI, there were roughly 87,500 ACSC admissions to Canadian hospitals, outside Quebec. This number jumps to over 114,500 when one includes Quebec. At an average inpatient hospitalization cost of $7000 per patient ACSC hospitalization costs amount to over $801 million per year. 51 CIHI. Wide variation in potentially preventable hospitalizations for chronic conditions across Canada: New report highlights differences by region and by income level. News brief. May 29, 2008. Accessed at: http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_29may2008_e 52 NACHC. America’s Health Centers: Making Every Dollar Count. 2006 53 Khan S et al. Primary Health Care Teams and Their Impact on Processes and Outcomes of Care. Health Research. Working Paper Series. Health Information and Research Division, Statistics Canada. July 2008. p. 3 54 Ibid 55 Hogg W, et al. Comparison of Models of Primary Health Care in Ontario. Op cite. 56 Pineault R et al. Research Collective on the Organization of Primary Care Services in Québec: Summary Report. Direction de santé publique - Agence de développement de réseaux locaux de services de santé et de services sociaux de Montréal. 2005. 57 McColl MA et al. Access and Quality of Primary Care for People with Complex Care Needs: A Comparison of Three Payment Models. Queen‘s Centre for Health Services and Policy Research. October 2005. 58 CIHI. Physicians in Canada: Fee-for-Service Utilization, 2005-2006. Ottawa 2008 59 Ibid 60 Khan S et al. Primary Health Care Teams and Their Impact on Processes and Outcomes of Care. Health Research. Op cite. p. 4 61 Canadian Health Services Research Foundation (CHSRF). MythBusters – Myth: Seeing a nurse practitioner instead of a doctor is second-class care. 2002 29

Primary Health Care in Canada 62 Patzer K. A Review of the Trends and Benefits of Community Engagement and Local Community Governance in Health Care. Association of Ontario Health Centres. Toronto, June 2006. 63 Church, W.J.B. Technical Report - Citizen Participation Partnership Project. University of Alberta Centre for Health Promotion Studies. 2006. 64 Crampton P, et al. ―Does community-governed non profit primary care improve access to services? Cross-sectional survey of practice characteristics‖. International Journal of Health Services. 2005; 35 (3): 465-478. 65 Ibid 66 van Kemenade S. Social Capital as a Health Determinant: How It is Defined? Policy Research Division, Population and Public Health Branch, Health Canada Working Paper Series. March 2003. http://www.hcsc.gc.ca/iacb-dgiac/arad-draa/english/rmdd/wpapers/engsocial.pdf 67 Wallerstein N. What is the Evidence on Effectiveness of Empowerment to Improve Health? WHO Regional Office for Europe Health Evidence Network Report. 1 February 2006. 68 Gardner B. ―Building Action on the Social Determinants of Health‖. Presentation to the Senate Subcommittee on Population Health. March, 2009. Available at: http://www.wellesleyinstitute.com/files/WISenatesubcomtespknotesMarch1209.pdf . 30

Scott a wolfe enhancing primary care and health equity in canada wellesley institute may 2010

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Scott a wolfe enhancing primary care and health equity in canada wellesley institute may 2010 — Document Transcript