FINA Committee Meeting

STANDING COMMITTEE ON FINANCE

COMITÉ PERMANENT DES FINANCES

EVIDENCE

[Recorded by Electronic Apparatus]

Tuesday, November 30, 1999

• 0930

[English]

The Chair (Mr. Maurizio Bevilacqua (Vaughan—King—Aurora, Lib.)): I'll call the meeting to order and welcome everyone here this morning.

As you know, the finance committee has been travelling from coast to coast, listening to Canadians and seeking their input on what the elements of the 2000 budget should be. And it's not only been doing that. As you probably know, when the Minister of Finance delivered his economic and fiscal update in London, he also asked us to comment on a five-year plan, so we'll be seeking input for that as well.

Many of you have previously appeared before the committee, so you probably know how this works. You have five to seven minutes to make your presentation. Thereafter, we'll engage in a question-and-answer session.

We will begin with the Canadian Dental Association, but before we do that, I'd like to introduce all the other organizations that are here this morning. We have the Canadian Dental Association, the Canadian Healthcare Association, the Canadian Medical Association, the Canadian Nurses Association, the Canadian Pharmacists Association, and the Health Action Lobby.

We will begin with the Canadian Dental Association and its president, Dr. John Diggens. Welcome.

Dr. John Diggens (President, Canadian Dental Association): Thank you, Mr. Chairman. It's a pleasure for me to appear before you today as the president of the Canadian Dental Association to take part in your pre-budget consultation process.

The Canadian Dental Association represents 16,000 dentists throughout the country. We're a national voice for dentistry in the country, dedicated to serving our members and, perhaps more importantly, to promoting optimum oral health for Canadians.

The CDA would like to compliment the House of Commons Standing Committee on Finance for once again conducting extensive pre-budget consultations in preparation for the next federal budget. Although our presentation does not directly address the consultation's five primary themes, our chosen issues and expertise will allow us to address tax relief and reform, social infrastructure and productivity. Again this year, we have chosen to discuss issues that have both a direct impact on our member dentists and a more global impact on dentistry in general and the oral health of Canadians.

Before I begin discussing our 1999 recommendations, I would once again touch on the issue of tax deductibility of dental plan premiums for Canada's unincorporated self-employed. Dental disease has been referred to as one of the most common health problems in the world today, yet because it's generally neither dramatic nor life-threatening, its overall health impact has not been fully appreciated. The Canadian Dental Association realizes that dental health can affect the functional, psychological, and social dimensions of an individual's overall health status. Dental health problems lead to a reduction in daily activities and a loss of productive work time, and they negatively affect the productivity of the Canadian economy.

The CDA supports optimum oral health for all Canadians, provided through a delivery system that is open and flexible and among one of the best in the world. Public funding has been most appropriate where the ability to pay is a barrier to access. The CDA will continue to work with government and other stakeholders to provide affordable access to oral health care for all Canadians. The CDA believes this is best accomplished through the improvements of the existing private and public delivery systems. No fundamental changes in the current delivery systems in Canada should take place without full consultation with all stakeholders.

In Canada, the quest for affordable, accessible oral health care has historically been a partnership of professionals, governments, businesses, and labour. This approach has helped to shape a private sector system that creates an incentive for prevention and promotes oral health maintenance.

All partners have made their individual contributions. Across Canada, dentistry has made significant strides in controlling cost increases. On average, fee increases for preventive oral health care, the familiar cleaning and checkup, have been less than the annual increases in the benchmark consumer price index for well over a decade. Employers have done their part by financing plans for their employees. Plan providers have designed some of the best plans in the world as their contribution to the partnership, and the federal government has provided a tax incentive of deductibility on planned premium costs for employers. Until the 1998 budget, this incentive was restricted and not available to unincorporated self-employed individuals in Canada.

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The CDA applauds all partners who supported the thrust to extend the deductibility of plans to the unincorporated self-employed. Mr. Chairman, we're particularly grateful to this committee for a specific recommendation calling for this action in the 1997 pre-budget report, and to the Minister of Finance for taking action in the 1998 budget.

The CDA applauds members of the Canadian Life and Health Insurance Association and the Canadian Federation of Independent Business for taking the initiative to market plans to incorporated businesses that have not yet offered benefits to their employees, and for developing and marketing plans to unincorporated businesses.

Mr. Chairman, I'd now like to turn my attention to an issue that's very important to the association and individual member dentists across the country. The issue is tobacco.

Dentists regularly see the effects of tobacco abuse in the course of their daily work. This alone provides more than sufficient motivation for our members to serve as a force against this ravaging abuse in our society. Through the CDA, dentistry has worked with Health Canada to spread the message of danger loudly and clearly. Regrettably, we find that the addictive power of tobacco products makes it difficult to persuade people who are hooked to give up the habit. For some who have been hooked almost all their adult lives, even the onset of devastating related illnesses cannot spur them to quit. The health risks of smoking for smokers and non-smokers are well established and numerous. Other forms of tobacco, such as smokeless tobacco, are harmful to health.

In Canada, Health Canada estimates that the societal cost attributed to smoking for 1993 was approximately $11 billion, of which $3 billion was spent on direct health care costs such as hospitalization and physician time, with the remaining $8 billion being due to loss of productivity, including forgoing household income. Labour Canada estimates that a smoking employee costs $2,308 to $2,613 more per year to employ than a non-smoker, as a result of absenteeism, increased health and life insurance premiums, and lost productivity. By comparison, it's estimated that for the fiscal year of 1993-94, federal excise taxes and duties totalled $2.6 billion, which is quite a bit less.

Mr. Chairman, the CDA supports Senator Colin Kenny's effort to pass legislation that would create a trust fund or foundation to educate children on the hazards of tobacco use. This involves the implementation of a tax on cigarette sales. We urge your committee to speak up on this issue and to include in your report recommendations that would help children avoid the perils of this terrible product.

Mr. Chairman, the other issue I would like to address is student fees and student loans. The CDA, like other professional associations, is concerned about the high and rapidly escalating professional tuition fees across Canada. In May 1998 the Province of Ontario deregulated tuition fees for training in areas that lead to professional careers such as dentistry. Although Ontario is the only province to deregulate tuition fees, throughout the country fees are escalating.

In the past, obtaining a dental degree was relatively affordable and accessible to individuals throughout the country regardless of their socio-economic background. Our primary concern is that the high tuition fees may create an imbalance in admissions to dental schools by favouring those who represent affluent segments of society, effectively closing the door on qualified applicants who cannot afford to attend dental school.

Mr. Chairman, we trust that your committee will take action on this very important issue. We recommend that funding for professional schools be increased, and that a financial support system for students recognize and adapt to the yearly fluctuations in tuition levels. When tuition fees increase, loans and bursaries should increase in direct proportion to those fee increases.

Mr. Chairman, our brief also includes a section of recommendations on the retirement income issue. The CDA is a member of two coalitions that made presentations to the government on this issue. The RRSP Alliance forwarded you their position earlier this fall, and the Retirement Income Coalition appeared before this committee on the evening of November 17.

Mr. Chairman, in closing, I want to once again thank you and your committee for conducting these worthwhile hearings. It's a pleasure to have the opportunity to put forward our recommendations in such an open and accessible forum.

The Chair: Thank you very much, Dr. Diggens.

We'll now hear from Ms. Sharon Sholzberg-Gray, from the Canadian Healthcare Association. Welcome.

Ms. Sharon Sholzberg-Gray (President and Chief Executive Officer, Canadian Healthcare Association): Thank you. I'm pleased to be here today on behalf of the Canadian Healthcare Association. We're the federation of provincial and territorial hospitals and health care organizations dedicated to strengthening our health care system. I'm also the co-chair of HEAL, the Health Action Lobby, and you'll be hearing from that group this morning as well.

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CHA is pleased to outline for the committee why funding for a sustainable, publicly funded health care system must be part of the 2000 federal budget. Health care remains a top priority for Canadians. The 1999 budget was a first step, but it was not enough for a sustainable system that meets the needs of Canadians. The budget only partially responded to past cuts, and didn't respond to future needs.

The $11.5 billion over five years added to the CHST, as announced in February, seems impressive. However, it will only address our health care system's most urgent problems. It won't address ongoing problems such as deficit financing by health authorities, hospitals, health care facilities and agencies to meet their obligations for care even when prohibited by law; frustration among health providers; the crisis in health human resources; capital expenditures to maintain physical plants and to integrate restructured programs; increased private sector financing, with a public-private ratio of approximately 70:30, surpassing the OECD average of 80:20; and disparities in what is covered under health insurance plans, resulting in greater privatization and individual out-of-pocket expenses.

The federal government has said—in fact, Paul Martin said it in his budget speech in February—that as the fiscal picture improved, health care would be a priority for future action. With a projected surplus of almost $100 billion over the next five years, the fiscal picture has improved, yet our health care system still faces significant challenges.

The health care sector has maintained quality care while coping with restrained funding, a growing and aging population, and technological change. But there is the danger—and it is happening—that federal cuts simply transferred the government's potential insolvency to the public health care sector.

CHA, as does HEAL, urges the federal government to commit at least $1.5 billion to the health care system by April 1, 2000, to stabilize the existing system and to support the development of a national home and community care program. We also urge the government to apply an escalator to the cash portion of the CHST by 2001 in order to ensure long-term sustainability for our health care system.

Some argue that our health care system has a voracious appetite for taxpayers' dollars. Supposedly, two-tiered health care that allows access based on the ability to pay and not on health need is more efficient and less expensive. This is incorrect for four reasons:

First, access based on health need and not on ability to pay is a core Canadian value. It is essential to our commitment to equity and our quality of life.

Second, publicly funded health care is a competitive advantage valued by the private sector. As Charles Baillie, the CEO of the TD Bank, said:

To set aside our single-payer, publicly funded universal healthcare system would not simply be a moral error, it would be a grave economic error. The fact is, the free market, efficient and desirable as it is, cannot work in the context of universal healthcare.

Third, public and private health care spending comes out of the same pocket, that of individual Canadians. Offloading to the private system is a false economy. The U.S. spends 14% of its GDP on health care, versus 9% for Canada, yet 40 million Americans are uninsured.

And fourth, the unplanned privatization of health care reduces government's ability to maintain national standards and weakens your ability to direct how health care funds are spent.

You might ask why the federal government should invest more in health care when some provinces have enough money already, you would say, to spend on health. We would answer that right now you're spending—and this is the most generous estimate—22% of the health care budget, although some people say it's as low as 8%, but we don't know because of the murkiness of the CHST. It seems to me, though, that the federal government has to have both the moral and the real authority to ensure that Canadians, wherever they live, have access to comparable standards across a broad range of services. It can't do this when it only contributes 22%. The federal government can do the right thing: take the high road and shift the political burden to those provinces that might be able to spend more on health but don't.

CHA urges the federal government, in collaboration with the provinces and territories, to support the development of a monitoring and evaluation process of private sector financing and delivery within our health care system, and to develop national standards for the involvement of the private sector in the delivery of both publicly and privately funded health care services.

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Adequate and long-term public funding is essential, but it's only one part of a sustainable health care system. CHA has given our discussion paper on sustainability to the committee's researcher, and we are pleased to provide copies to committee members. Our pre-budget brief and sustainability framework contain recommendations on health human resources, new funding mechanisms, accountability, health information, health research, and of course the important link between productivity and health.

We know there are competing demands for the surplus, including tax cuts and the needs of children. We support resources for children's issues. However, the federal government should avoid either/or scenarios, and should fiscally enhance both the health care system and the broader social infrastructure. Indeed, CHA encourages the government to focus on the health needs of Canadians at all life stages. And we'd like to say that we appreciate the funding in the 1999 budget to improve the health of aboriginal people, who have some of the greatest health needs in Canada.

The benefits of tax cuts compared to increased private investment in health care must be examined. Since income level and income disparities are determinants of health, tax cuts must narrow, not widen, income inequities in Canadian society. We should also be looking at targeting funding for health care. That can be more effective in enhancing quality of life than tax cuts can be in many instances.

CHA urges the federal government to show leadership through new, reasonable public investments in the 2000 budget in order to build a sustainable health care system, which is key for a productive, prosperous, and just Canada as we enter the 21st century.

Thank you.

The Chair: Thank you very much.

We'll now hear from the Canadian Medical Association's president, Dr. Hugh Scully, and Dr. Peter Vaughan, its secretary general and chief executive officer. Welcome.

Dr. Hugh Scully (President, Canadian Medical Association): Thank you, Mr. Chairman.

I'm Dr. Hugh Scully, president of the Canadian Medical Association. Today I sit here representing the 47,000 physicians out of the 56,000 practising physicians in the country who are members of the Canadian Medical Association.

The mission of our organization is to promote the highest standards of health and health care for Canadians. That brings us before you today and fuels our dedication to ensure that Canada continues to have a high-quality, accessible, and—as you've heard already from others—sustainable health care system.

The last time we appeared before the committee we urged in the strongest possible terms that the government demonstrate strategic leadership by reinvesting in our national health care system. In the federal budget of this past year, we were very pleased to see the government take an important first step, but there's still a need for a long-term federal cash commitment if we are to ensure a sustainable health care system for Canadians. Sustainability really is the focus of our pre-budget consultation brief. You have that in some detail before you, and it will be the focus of my comments today.

The reinvestment of $11.5 billion over a five-year period in last year's budget was an important signal, and it was certainly needed. However, with the complete restoration of federal cash by 2003-04, the health care system will only be back at its 1995 nominal level some seven years after the fact, with no recognition of the aging population, and the attendant increase in health care needs, inflation, technology development, and economic growth.

Last year's reinvestment focused on the crisis in the health care system, but it did fail to address some of the other key concerns. The first of these is the indexing of cash entitlements through an escalator in the Canada health and social transfer. There is a critical shortage of health care providers, physicians, nurses and others, and we do need to begin the process of expanding the continuum of care beyond what has been traditionally embraced within medicare in this country.

To facilitate the continuing stabilization and sustainability of the health care system, we are recommending that the federal government, at a minimum, increase federal cash for health care by an additional $1.5 billion effective April 1, 2000. We're very much in concurrence with the CHA and with HEAL, of which we also are a member. And we'd echo the words of the Prime Minister, who said in a speech in the spring:

In Canada, we consider Medicare to be the best example of how good social policy can be good economic policy. While reflecting the desire of Canadians to show compassion for their fellow citizens, Medicare also serves as one of our key competitive advantages.

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An issue that remains a concern to the CMA is the lack of a health-specific portion of federal cash transferred under the CHST. While the federal, provincial, and territorial governments may have an understanding as to the distribution of funds under that arrangement, we also understand that government priorities can change. We believe that Canadians both want and deserve to know if their taxpayer money is going to fund programs for which it is intended. This is a straightforward issue of accountability, something the Honourable Allan Rock, as Minister of Health, has talked about many times, certainly with us, and in other fora. This would be full recognition of the reinvestment of federal money into the health system.

A health-specific portion of the CHST would address this issue and at the same time promote transparency and visibility of federal cash transfers to the provinces and the territories. In the context of the full restoration of the CHST, something that is endorsed by the premiers, the finance ministers, and all ministers of health, it should also be pointed out that educational costs of increased enrolment in medical schools and costs of increased opportunities for further training and research should not be borne solely by the health budget.

Now, Canadians have told us time and again that they fear the health system won't be there for them when they need it. The federal government must address the future needs of our population and ensure that it will be. We're certainly happy to work with you to realize that objective.

A combination of population growth and aging, the expanding knowledge base, and the emerging technology will put a level of demand on the system that we simply haven't seen before. If current funding policies continue, the strain will soon overwhelm the system. The critical issue is what immediate, successive steps can be taken to place the funding of our health care system on a long-term, sustainable basis.

One of the points I made about last year's initiative is that what it did was to take the health care patient out of intensive care and move them back to the step-down unit or onto the floor, but that's a long way away from being discharged to home. If we don't address this, we'll be back in intensive care very soon. There is a need for a fully-indexed escalator to ensure that the federal cash contribution will continue to grow to meet the future needs of Canadians.

The viability of the health care system is certainly dependent on a healthy health care workforce. An adequate physician population, an adequate nursing population, and an adequate health professional population are essential to the efficient operation of the system. We certainly don't have that today, and if current policies and practice models continue, the situation will get worse.

In the medical schools of Canada, we have seen a reduction of 17% in enrolment since the beginning of this decade. That translates into a 30% reduction in opportunity for Canadian students to attend medical school—the worst record in the western world.

We have an aging physician population. For example, today there are 6,000 physicians over the age of 65 actively working full-time in practice and 2,000 over the age of 70, many of whom would like to retire. We do have 1,000 physicians a year retiring now. That will be up to 1,100 by 2010 and 1,500 by 2020.

The issue of the brain drain has captured attention, and certainly when it comes to physicians, that's very true. We've lost approximately 4,000 over the last decade, mostly to the United States, many of those shortly after graduation, another quarter of those in the full bloom of practice. That's an export we simply can't afford.

Many areas of Canada, both urban and rural, are trying to cope with the impact of a shortage in physician supply, not just in rural and remote areas, but now increasingly in smaller communities and in major urban centres. Immediate action must be taken to repatriate Canadian physicians—many of whom continue to maintain their Canadian licences although out of the country—as well as to develop policies to recruit and retain Canadians in this country.

In concluding, Mr. Chairman, the CMA believes that the recommendations contained in our brief are powerful and a strategic package for Canada, not just for this year, but as you pointed out at the beginning, over the next five years and beyond. Taken together, they'll help to stabilize the health care system and ensure that Canadians continue to get access to the health care they need.

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Let me point out—I haven't touched on it—that there are detailed recommendations commending the developments in health research and recommending that they continue. We've addressed tobacco control initiatives, which was well articulated in the presentation of the dental association. There's the issue of GST and physician services, RRSP contribution limits, tobacco control initiatives, and the others.

I urge you, Mr. Chairman and all committee members, to ensure that the federal budget does reflect the recommendations presented here today.

Thank you.

The Chair: Thank you very much, Dr. Scully.

We'll now hear from the Canadian Nurses Association, with Dr. Mary Ellen Jeans, executive director. Welcome.

Dr. Mary Ellen Jeans (Executive Director, Canadian Nurses Association): Thank you. I'm pleased to have the opportunity to present nurses' recommendations for the federal budget of 2000.

CNA is the voice of registered nurses across Canada. Our mission is to advance the quality of nursing care in the interest of the public. Our work includes public policy development, both domestic and international, as well as articulation of national standards of practice and the certification of nursing specialties.

I am also the co-chair of the Health Action Lobby, and CNA is a member of the National Children's Alliance. Both of these coalitions, I believe, are presenting to this committee.

What I will describe today is stark and contains disturbing events and situations. Perhaps my brief should carry a label: listener discretion advised. My presentation will be in two parts. Each of them reflects a nursing lens.

First I'll look at the health system in 1999 and the impact of the last federal budget. I'll describe the challenges facing the nursing profession. You'll recognize some of the points, perhaps from personal experience or from the experiences of your constituents. Finally, I'll offer priorities for investment to address the challenges of both the health system and the nursing profession.

Our health system revolves around institutions and infrastructure. This fact is confirmed by the application of the 1999 federal budget. The majority of the $2 billion federal increase was used to pay operating deficits of health care facilities across the country.

And why not? There's no clear vision of the health system, its various components, and how they work together in an integrated continuum, and there's no evidence that access to quality health care has improved. Were the injected funds put to advancing alternative health services or their delivery? Where's the investment in expanding and integrating “tele-health”? Where's the investment in restoring a client focus to the design of the health system? Where's the investment in community-based health services like public health nursing, health promotion, and disease prevention?

In Hawaii, South Africa, the State of Victoria in Australia, and New Zealand, they have universal postnatal home visiting programs. That means that a public health nurse sees every newborn and every mom several times in the first few months following delivery. The visits allow for early detection of health and/or learning and developmental problems. The nurses ensure early referral to specialized care and treatment as needed. They provide support to new moms.

Child development literature has repeatedly confirmed the social, psychological, health, and economic benefits of home visiting programs, and yet I'm hard pressed to identify one dollar from last year's budget allocation that went toward a national program for all Canadian newborns.

A similar story can be told about school nurses. How many of us remember the role that the school nurse played in classroom learning on topics such as hygiene, healthy sexuality, disease prevention, etc.? How many of us remember consulting a nurse about some malady, seeking care for a schoolyard mishap, or seeking advice on stress management and peer relationships? Will it surprise you to learn that children cannot access a nurse at the school any more?

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Among developed nations, Canada has the highest rate of teen suicide. Canada has little to be proud of, with a growing rate of both teen pregnancy and sexually transmitted diseases.

What are we doing about turning those trends around? Again, the literature speaks to the value to children of accessible support—trusted, credible adults. I cannot identify any government investment in ensuring child and teen public health programs within the health or education systems.

On November 4 Statistics Canada released the results of a survey showing that over 2.1 million Canadians, or 11% of our adult population, are caring for relatives. The burden on families who are caring for the sick and the recovering was not addressed by last year's budget.

The implications for Canada's productivity are huge. I know that patients are being discharged earlier. Home care nurses are seeing individuals who are unable, for financial reasons, to pursue the treatments and services being prescribed.

Neither medicare nor private insurance is coping with the reality of home care. “Out of pocket” is the mildest descriptor for Canadians with health challenges, and “unwell” and “unlikely to recover fully” are two others.

The trend in injuries in this country is staggering. Rehabilitation and return to productive work requires nursing services, physiotherapy, occupational therapy, and often psychological therapy. None of these key services is fully covered in the current health care system. Last year's budget did nothing to address this abyss.

I'm not seeing any evidence that the problems of access to quality health care have been dealt with; in fact, quite the opposite. Operating rooms across the country are being closed. We hear it's due to lack of staff. In northern Manitoba, nursing services have disappeared due to the absence of staff. I hear about people waiting three days to have broken legs set. Again, staff shortages are blamed. I read about a 12- to 19-week delay in cancer treatment in Ontario. The culprit? Staff shortages.

In the Northwest Territories there's a 33% vacancy rate for nursing jobs. Hospital beds have been closed in St. John's, Newfoundland, because staff cannot be found.

I know that nurses working in hospitals are seeing patients who are sicker. I'll speak more about the impact of this phenomenon later. Suffice it to say that if the access problems were being addressed, the acuity issue would have begun to reverse itself.

The challenges facing the nursing sector in Canada are no different from those in other developed nations, except for Japan and Germany, with the exception of one thing, which I'd like to highlight. All of the countries in the world are experiencing shortages of professional nurses; an aging workforce; job insecurity; problems of access to nursing services in remote and rural areas; underemployment of nurses; growing job dissatisfaction; and declining enrolment in nursing programs at universities and colleges. The one thing that is different in Canada is this phenomenon of casualization. Nowhere else in the industrialized world has a government health care system resorted to putting their professional nursing staff on a casual-employment basis, which has devastated the profession in Canada.

The diagnosis for the nursing sector in Canada is devastating and the prognosis is grim. The average age of nurses is 45 years. Most nurses begin to retire by age 56. Similar to what Dr. Scully has presented, you're going to see a continuing retirement of experienced nurses over the next ten years.

The number of students graduating from nursing education programs in Canada has stagnated since 1993. Prior to 1990 we graduated 10,000 nurses in this country. Today it is closer to 4,000. This is an incredible decrease in the supply of new nurses to the health care system.

A 1999 labour market survey shows that three of ten nursing graduates leave the profession within three years. Half the members of the nursing workforce do not have permanent or full-time jobs, and 25% have multiple employers. These are the nurses who are working on a casual basis.

Between 1991 and 1998, the number of nurses working in hospitals fell by 14%. Nurse-to-patient ratios are going in the wrong direction to allow for safe or competent care.

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These numbers do not reflect the fact that many of the patients who are using nursing services are sicker than those in 1998, and it does not account for the increasing demands for nursing care of an aging population.

In many cases, nurses with a certified specialty in critical care are on call 24 hours a day, seven days a week, 12 months a year. Safe care is under threat. Occupational health is jeopardized.

Canada's capacity to educate new nurses is disappearing with the retirement of the current cadre of professors and the scarcity of students at the master's or PhD level. Between 1991 and 1998 the number of nurses employed in teaching institutions fell by 37%.

A 1999 report of the Conference Board of Canada shows that the equivalent of 50% of last year's graduating nurses emigrated to the United States. Last year's budget did not provide for the development and implementation of recruitment and retention strategies for health service providers. You may recall that we did request targeted funding to restore the nursing workforce in Canada. We asked for some $200 million to address recruitment and retention strategies. While we appreciated the $25 million research fund, this hardly can address the seriousness of the workforce needs in nursing.

Two experts in the area of health human resources, Morris Barer and Greg Stoddart, have presented arguments about the need for bold action on health human resource planning in Canada, about the need to change paradigms, to question the current allocation of tasks among providers. Their most recent comments focused on health professionals in rural and remote areas.

Health professionals agree that the government must invest in ensuring the appropriate supply, mix, and distribution of the health workforce. It must support professional development and education to ensure that Canada's health providers remain world-class.

Of course, to be effective, health human resource strategies need to start from a vision of the health system. That vision, as I stated earlier, is lacking.

In terms of priorities, we believe funding needs to be allocated to supplement the previous and current investments in health. Specifically, resources are needed, and quickly, for the development of a vision for Canada's health system, one based on primary health care where all health care professionals are a point of access to necessary health care for Canadians.

Secondly, resources are needed immediately to advance components of the health system, including community-based health services and their integration with the current health care infrastructure. An early investment should be made in services that support children and youth.

Thirdly, resources are needed to support strategies to address the issues of recruitment and retention, distribution, and the roles of health care professionals. I can't emphasize this enough. If something isn't done immediately, the integrity of Canada's health care system is seriously at risk. Nurses make up 75% of health care professionals. They really form the glue of the system, and they've been devastated by the ten years of cutbacks. If we don't do something this year, I truly believe we may be too late.

Canada's health system depends on a partnership among individual Canadians, health professionals, and governments. The role of health professionals is to provide expert advice and care. Without them there can be no health system.

Governments' roles are to provide strategic leadership, vision, and sustainable funding to the health system. As Canadians know, the decision by governments to withdraw funding kick-started the deterioration of the publicly funded health system, and with privatization and threats of global trade in health services, shortages of health professionals are the result.

I'm pleased to table with you a copy of our pre-budget submission and to respond to any questions.

Thank you.

The Chair: Thank you very much, Dr. Jeans.

We'll now hear from the Canadian Pharmacists Association, Dr. Jeff Poston and Ms. Noëlle-Dominique Willems. Welcome.

Dr. Jeff W. Poston (Executive Director, Canadian Pharmacists Association): Thank you very much, Mr. Chairman. I'd like to thank you for the opportunity to appear before the committee.

I represent the Canadian Pharmacists Association. We're the national voluntary association representing pharmacists in practice in both community and hospital pharmacy. We also have pharmacists working in industry and academia.

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As pharmacists, we have a keen interest in ensuring that all Canadians have access to the medications they need to treat acute and chronic illnesses. Therefore, when the Liberal government's red book had a commitment in it to develop a national pharmacare initiative, we certainly applauded that proposal. We believe the need for a national pharmacare program is being supported by numerous consumer surveys that rank improved access to medications as a high priority for Canadian citizens.

Pharmacists in everyday practice see the dilemmas that are created by the inadequate funding of drug plans in Canada. Certain patients are forced to make very difficult choices.

In conjunction with most pharmacy associations from across the country, the Canadian Pharmacists Association has developed a discussion paper on the components we feel are necessary to constitute a national pharmacare program, and the roles of all participants in such a program. We've distributed this to the committee. We apologize that the French version is not yet available.

For this consultation, we felt the pharmacists as experts in the field should contribute their knowledge and experience to the debate on pharmacare. We're pleased to submit this document, since in addition to examining the rules and responsibilities of all, it also outlines the potential costs of such a program and the implementation phases that are going to be necessary to implement it.

We wish to build on the foundation laid by all levels of government through the federal-provincial-territorial pharmaceutical issues committee and contribute to the building process of this important program to the health of all Canadians.

Continual work is going to be needed to develop the drug benefit component of the Canadian health care system. Drug therapy is clearly one of the most cost-effective interventions available in modern health care. Yet we see costs continuing to increase. It's certainly driven by an aging population and the increased elderly population we're going to see as we get into the early part of the new millennium, and also ever-advancing technology. We get newer and better drugs on a regular annual basis. When the magic bullet for cancer is found, which perhaps we all hope would be a certainty for the new millennium, will we be able to afford this cure for all of our citizens?

If we are going to achieve that goal, we believe we need to start planning now. We need to establish a long-term plan to make pharmacare a reality for all Canadians. An incremental approach is needed to build on the work already done by the provinces. The Canadian Pharmacists Association would like to recommend the following steps for funding allocation in the upcoming budget.

First, as with the Quebec pharmacare plan, there should be an initial move for a national program to cover those citizens that have no coverage at all at present. Based on experience gained in Quebec, we would estimate this would apply to about 14% of the Canadian population.

Further, we believe that because of the mobility of the labour force, and as we see increasing mobility in the labour force in Canada, and more people working part-time who do not benefit from extended insurance coverage, there's a need to establish a temporary bridging program that would be accessible to people receiving employment insurance, those between jobs, and people in workplaces where there is no employer-sponsored insurance plan. This would be a temporary measure that would remain until the full pharmacare program had been implemented.

As identified in the program in Quebec, there is also a need to ensure that whatever their circumstances, children are covered. This is in line with current Canadian and international values with respect to the health of children. It's in line with the government strategy to address child poverty in Canada. Therefore, we suggest that consideration be given to providing free drug coverage to all children up to the age of 18 years, as well as to women during pregnancy.

Finally, we would recommend that the drug therapy programs be extended to cover people in home care programs across the country. The Canadian Nurses Association alluded to the gaps that exist in community care and in home care. We think this is an important one. We further recommend that once this component of coverage would be integrated into a national pharmacare program, the problem you have is with early discharge from hospital. Many patients who have their drugs covered while in hospital go into a home care situation where they may not have adequate coverage to meet their medication needs.

To start implementing these steps, the Canadian Pharmacists Association recommends that the federal government allocate $1 billion per year for the next three years in transfers to the provinces for the specific purpose of providing medication coverage to the segments of population we have described.

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I'd also like to add to the concerns that have been expressed by colleagues from the Canadian Medical Association and Canadian Nurses Association with respect to health human resources in Canada. We're facing a critical shortage of pharmacists at the moment, and many of the issues relating to an aging professional population that affect medicine and nursing also apply to pharmacy.

We share the concerns echoed by the Canadian Dental Association with respect to the increases in tuition fees as a result of deregulation. We see this is going to create a significant barrier to access to professional education schools for many high school graduates.

Thank you very much.

The Chair: Thank you very much, Dr. Poston.

We'll now hear from the Health Action Lobby, Mr. Dan Stapleton, CEO, Canadian Physiotherapy Association. Welcome.

Mr. Dan Stapleton (Chief Executive Officer, Canadian Physiotherapy Association; Health Action Lobby): Mr. Chairman, ladies and gentlemen, good morning.

My name is Dan Stapleton. I'm chief executive officer of the Canadian Physiotherapy Association. Today I am pleased to be here representing the Health Action Lobby, or HEAL, as we're known.

HEAL is a coalition of 29 national health and consumer organizations. We have long been part of the pre-budget consultation process and have appeared before this committee each year since our inception in 1990.

We welcome the opportunity to present to you our perspective on why Canada's publicly funded health care system should be among the federal government's top priorities for the 2000 budget and beyond into the 21st century.

The HEAL message remains consistent: As a precondition for a productive and prosperous Canada in the next century we require a strong and sustainable health care system. While we appreciate the investments in health programs made by the federal government in the 1999 budget, they are only a first step. The job is not done, a fact recognized by the Minister of Finance himself.

Canadians remain concerned about our much-valued publicly funded health care system and our ability to continue to provide quality care in the face of a growing and aging population. Issues of diminished access, the increasing physical, psychological, and financial burden of caring placed on families, and the high cost of essential pharmaceutical therapies, especially in community settings, continue to be of grave concern.

HEAL believes it is time for change in the health care system—not the deficit-driven, unplanned changes that we experienced throughout the 1990s, but true change inspired by a shared vision of all governments, consumers, and health care providers. We hope that in the climate of renewed federal, provincial, and territorial relationships, the federal government will work toward the development of a vision of health care that will meet the needs of Canadians in the 21st century.

This vision must seek to both strengthen the current system, ensuring it is adequately funded, and address the emerging needs of Canadians by improving access to an expanded continuum of care. By this we mean not only expanding the publicly funded system to include home and community care, but a recognition that many essential services, such as mental health care and physiotherapy services, are currently covered in only a very limited way by the Canada Health Act within the current system. We recommend the federal government work collaboratively with health stakeholders, non-governmental organizations, and the public to develop an implementation plan for this vision.

HEAL also recommends the government continue to work with stakeholders such as HEAL and the public to address the current funding of insured services to support the transition to a broad continuum of community-based services within the insured services envelope and to facilitate the development of a comprehensive, seamless system of care.

With respect to the current level of federal funding support for health care, the 1999 budget announcement of a reinvestment of $11.5 billion cumulatively over five years was welcomed as a first step, but it was not enough. Analysis of this formula demonstrates that the health system will only return to its 1995 nominal levels seven years after the fact, with no adjustment for the increasing health needs of Canadians, an increasing and aging population, inflation or economic growth.

The federal share of health care funding has declined from 50% to approximately 22% since publicly funded health care was introduced.

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The move to a more comprehensive system of care must be accompanied by a significant long-term and sustainable funding commitment of new money by the federal government. HEAL recommends that the federal government increase federal cash for health care by an additional $1.5 billion effective April 2000. We also encourage the government, as we have in the past, to establish an escalator for the cash transfer, effective April 2001, that will take into account population growth, aging, new technologies, and economic growth.

The mechanisms used to transfer federal funds for health is another area that remains of concern to HEAL. We are currently working on a project in this area with a view to examining options other than the Canada health and social transfer, which does not explicitly recognize or account for the contribution of the federal government to health. As we move into the next century, the concepts of accountability, transparency, and visibility should be reflected in fiscal transfer arrangements as explicitly as they are in other areas of federal responsibility.

If we are to provide a sustainable health care system for the future, it is critical that we take action now to ensure that we have the right types and number of health care providers. While the media has focused on the nursing and physician shortages sweeping the country, other health care professionals, such as pharmacists and psychologists, and paraprofessionals such as home care workers, are also in short supply.

It is not an easy issue, and there are no quick fixes. Public promises to hire more nurses, doctors, or pharmacists do not solve the problem if there are no nurses, physicians, or pharmacists to hire. HEAL members want to work with the federal government on a long-term integrated human resource plan, and we are encouraged that this issue was a priority at the recent meeting of the federal, provincial, and territorial health ministers.

Finally, the Health Action Lobby would like to commend the government on its recent announcements in support of health research and information sharing. We must build on these investments to ensure that the results of research are broadly shared and that our health care decisions are based on evidence and best practices.

The members of HEAL remain committed to preserving and strengthening Canada's publicly funded health system. Canadians want a sustainable, accessible health care system that meets their needs. The strength of the HEAL coalition is the great depth of our experience, our knowledge of the health care field, and our commitment to a publicly funded health care system to ensure it is there for Canadians and their families when they need it.

As the government implements the vision for the Canada of the 21st century as outlined in the Speech from the Throne, we urge you to remember that Canada's most valued asset truly is our people. Keeping Canadians healthy is the best investment you can make.

Thank you.

The Chair: Thank you very much, Mr. Stapleton.

We're now going to the question and answer session. We'll have time for a seven-minute round. If we keep the preambles tight, we'll get more questions in.

Mr. Paul Forseth (New Westminster—Coquitlam—Burnaby, Ref.): Okay, we'll try to do that.

Thank you for coming today. I'll address my comment or perhaps a more thoughtful type of question to all presenters, anyone who wants to respond.

You'll recall that the previous health minister, Diane Marleau, said of this present government that there is enough money in the system; it just must be spent more wisely. In other words, no new significant increases in health care funding were likely beyond present levels, especially in view of the increases that were given last year.

We know there will never be enough money to go around for social spending, so besides all presenters today just arguing for more allocation in their particular sector.... It's interesting that every single presenter who has come before this committee—it doesn't matter whether they're from the financial sector, environmental concerns, research, culture, and on and on—wants a reallocation to their sector.

Besides just asking for more for yourself at the expense of another sector, and by implication, then, saying your sector is more worthy than the other, when you look at the long term and you're seeing the need for sustainable health care spending and the growing need for more resources, what advice do you have for your interest, to go beyond just arguing for a larger piece of the pie to see actually a larger pie, so that more money will indeed come your way? Certainly when asking you know the dilemma of governance and limited resources, so what is your advice on how you will actually get what you think is needed?

The Chair: Dr. Scully.

Dr. Hugh Scully: Thank you, Mr. Chairman.

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I think that's a very germane question, and I would point out that I think all parties present this morning have recommended sustainability and a fair share, recognizing that of course there are other priorities and the business of government is to deal with competing priorities.

What we pointed out is that there was a withdrawal of funding and a diminution in funding that went on over some time, particularly in terms of the federal transfers. What happened last year was a move back to where we were. What is recommended today and for the future is an indexing to allow us to keep track of what's happening with the population in Canada and with the economy as it grows as it's predicted to do.

So we're not asking for a disproportionate amount. We understand there has to be balance. We're certainly asking for sufficient to maintain and develop the system as we move forward.

Mr. Paul Forseth: Does any other sector want to answer?

Ms. Sharon Sholzberg-Gray: Yes, I do.

As many people have noted, we can't grow the economy without having a productive economy, and I think we've made a clear link between the health of Canadians and their productivity.

We also can't grow the economy unless we're economically competitive, and many business people, including the Conference Board of Canada and the CEO of TD Bank, have said that our health care system is a very important part of our economic competitiveness, without which we couldn't grow. So if you're talking about the link between health and growth, we think there's a very real link.

In addition to that, we've made it very clear that we're asking for a very reasonable growth in the amount of transfers to the provinces for health. We're not asking for $6 billion, $7 billion, or $8 billion a year. All we're asking for is an index to keep pace with the growth in population and with the growth in the economy. So we're trying to be very modest in our requests.

The final point I would like to make is that if the publicly funded system doesn't meet the health care needs of Canadians, it's not as if there still won't have to be a way to meet those health needs, because they have to be met. In the end, all Canadians will have to pay, whether it's through the private sector or the publicly funded sector.

I think we've demonstrated that it's very efficient to do it in a single-payer medicare system. It's not as if we're going to save money if somehow the government pays less and somebody else—employers, individual Canadians, and other sources—pays more. So in fact we have to find the most efficient and effective way of funding the system. We think it's through that single-payer system. I think ours is really the blueprint for growing the economy and assuring the health of Canadians at the same time.

Mr. Paul Forseth: Okay. Maybe I can come at it from a different angle. We heard from the pharmacists' sector. Specifically, they asked for about $1 billion. It's interesting to hear from the various voices today, doctors, nurses, pharmacists, and so on, each wanting more for their sector. So I put it this way: To what extent do your sectors talk and negotiate with each other to present a more cogent single voice of priority ranking for applying limited tax revenues?

The Chair: Dr. Scully.

Dr. Hugh Scully: Thank you for the question.

I think I would come back to the consistency of presentation across this end of the table. When we talk about $1.5 billion being added in for this year, this is for all these sectors. This isn't specifically only for physicians, only for nurses. The Health Action Lobby, as was pointed out, does have many members, and collectively we do have many meetings. I think you'll find a consistency in the brief that's before you in the request that's there for sustainability.

Mr. Paul Forseth: Does anyone else want to respond?

The Chair: If you don't mind, I want to take you back to a question you asked, in relation to what Ms. Sholzberg-Gray mentioned. You want to tie the funding to growth in the economy and the population growth. What happens when the growth in the economy declines? Do health needs of Canadians decline at the same time?

Ms. Sharon Sholzberg-Gray: That's a very good point, and that's where it's really important that some time ago the federal government committed to a cash floor below which cash will not fall. I think it is a problem. That's why we also wouldn't necessarily say that the formula should be one year at a time—that is, the growth in GDP over one year—but rather a kind of moving average link and that kind of thing.

We haven't exactly figured out from a technical perspective how the escalator should work. We just know that without an escalator, the cash portion is going to fall behind. Over time, we feel that there will be growth in the economy. I don't think it's likely that the economy will be smaller ten years from now than it is today, so over time there will be that escalator. Granted, sometimes the economy might fall back or might not grow, and that's why we want to average it out over a few years at a time.

The Chair: Okay, thank you.

Mr. Forseth.

Mr. Paul Forseth: I think there is another presenter who wants to speak.

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Dr. Jeff Poston: Yes. I just wanted to respond.

Our request for funding of pharmacare isn't funding any particular sector, it's really looking at the health care needs of Canadians. Drug therapy represents excellent value for money. It keeps people in the workforce, and it makes a major contribution to the economy through enabling the population to work.

So it's not funding for a specific sector. It's a question of expanding coverage. Our specific proposals look at extending coverage, extending the safety net to look after those patients who are without coverage at the moment.

The Chair: Thank you, Dr. Poston.

Now we have Ms. Leung, Dr. Bennett, Mr. Gallaway, and Mrs. Redman.

Ms. Sophia Leung (Vancouver Kingsway, Lib.): Thank you, Mr. Chair.

I want to thank you all for sharing your ideas and recommendations. I also want to extend a welcome to Dr. Diggens from Vancouver, the president of CDA.

I've heard a lot of concern about the shortage of professionals in different professions, and we know it's quite a concern. We've heard that from many other sources too. How are we really going to handle this? I think Dr. Scully could comment, as well as Ms. Sholzberg-Gray, Dr. Diggens, and Dr. Jeans.

The Chair: Who wants to begin—Dr. Scully, Dr. Jeans?

Dr. Hugh Scully: Thank you for that question.

I did point out that there had been a decrease in enrolment and a decreased opportunity.

We have some very specific recommendations, which in fact were brought to the Minister of Health, the Deputy Minister of Health, and ministers and deputies from across the country last week. The first, and the one that provides the most return in the short term because of the shortage we have, is to make efforts to repatriate Canadians who have maintained their licences and who have left the country.

Secondly, we do need to have very constructive recruitment and retention strategies, and many communities are beginning to move in that direction. That becomes particularly germane and pertinent, of course, in rural and remote areas, but it is now becoming equally important even in urban centres and academic centres, as there's a great shortage of some specialists.

In order to meet the supply in the intermediate and longer term—recognizing that medical school is four years, then it's two years to family practice, and anywhere from four to eight or nine years for a specialty after that—we do need to increase enrolment in the medical schools to a modest degree.

Very importantly, we need to increase the post-graduate complement, or the post-graduate pool of positions for three reasons: firstly, to provide more flexibility, so that if there is an area of short supply, those in an area that's adequately supplied can move into that arena; secondly, to allow for re-entry from practice to training, which has traditionally been the source of specialists like anaesthetists, obstetricians, psychiatrists, laboratory physicians, and the like, where 40% to 50% of practitioners were in practice and came back; and thirdly and very importantly, to increase our capability of evaluating academically qualified—and I stress that—international graduates to come into practice.

Twenty-five percent of practising physicians in this country graduated from elsewhere than Canada, and they've contributed enormously to the quality of medicine and to life in Canada. But all of them have had the academic credentials that allowed them to get in, and we think that should happen.

So these are some of the moves that can take place that have return on that investment, both in the short term and the intermediate term, as we look at what's happening with the aging physician population and the rates of retirement that will escalate as time goes by.

The Chair: Dr. Jeans.

Ms. Sophia Leung: I just wanted one comment. I believe also there's quite a reduction for the student enrolment in the professional schools. Why is that not coordinated with the shortage in the meantime?

The Chair: Thank you, Ms. Leung.

Dr. Jeans.

Dr. Mary Ellen Jeans: Thank you.

We also met last week with the federal and provincial and territorial ministers of health, and what we proposed is an integrated strategy.

First of all, I need to emphasize that what has happened to nursing—and the situation is a little bit different from medicine—is that the cuts that have been made over the last ten years have in part created the problem we find ourselves in. What we're asking for in terms of funding for health care is to bring this back to where we were before all of this damage, if you like, was done.

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We need to stop the casualization of the profession. We need to provide full-time and permanent part-time jobs to nurses in the system. We need to make the working environment supportive of professional practice. Right now it is very, very sad in most of our health institutions across the country. Nurses are working 140%. The rewards for doing so are not there. They need adequate salaries like anyone else. They need continuing professional education to keep pace with the development of new knowledge, evidence, and technology.

So we have to correct the working environment of nurses in order to make it attractive for young people to come into the system. Then we do have to look at the recruitment end of it. You can see that the drop in the numbers of nurses graduating is incredibly significant. And it will take resources. We may have to offer scholarships or some kinds of incentives to attract young people into our educational programs for nurses.

We also have a huge number of nurses who have gone south. We'd like to be able to attract them back, but right now our system isn't at all competitive in terms of incentives. Americans are up here aggressively offering better salaries, offering to pay for continuing and advanced education, and so on.

There's a whole series of things that has to be done, but they have to be done in an integrated way and the strategy has to be national. Otherwise, you're going to have provinces competing with each other, and the nurses will be swinging from one side of the country to the other to where the highest incentives are offered, and that's not going to help the Canadian population. So we want a national strategy.

The Chair: Thank you, Dr. Jeans.

Dr. Bennett.

Ms. Carolyn Bennett (St. Paul's, Lib.): Thank you, Mr. Chair.

Firstly, I want to thank Miss Sholzberg-Gray from the Canadian Healthcare Association for her sustainability plug in terms of developing appropriate accountability mechanisms, health systems and health services research, and the productivity question. I come from all of this, and I was concerned that the issue of sustainability actually has to deal not with sustainable funding, but a sustainable system, and a sustainable system will be possible only if we actually are accountable.

I would like all of the panellists—or anybody who wants to—to talk a little about two things. One would be the University of Ottawa and Queen's University paper in 1995 that said if we actually looked at sustainability of the system and accountability, we'd see there's $7 billion of savings in the system that aren't being utilized, from people not being in the right level of care, unnecessary surgery, antibiotics, lab tests—where we have the incentives. And there's the fact that when we did our productivity round table, Stats Canada actually didn't have any data on productivity within the health care system, because we don't keep those numbers or we don't know what we're doing, and CIHI data is just on billing information that's sometimes skewed. We aren't actually measuring quality care in the way we need to.

So I want to start from there. What I'd like to do is ask the CMA and the CNA what they think of recommendations 7 and 9 from the HEAL coalition that talk about transparency, accountability, and best practices. Then I'd like to ask the HEAL action lobby why, in their brief, they have nothing about prevention—in terms of accident prevention or tobacco—which was well dealt with, I think, in some of the others.

I want to know why, when you have a coalition, you end up with some things that go forward and some things that don't. And why the Canadian Dental Association doesn't seem to be part of the HEAL coalition is another interesting observation.

I would like to know about accountability.

The Chair: Dr. Scully.

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Dr. Hugh Scully: Mr. Chairman, very briefly, I think accountability applies in many ways. What we've recommended in the brief—HEAL, CMA, CNA, and others—is a system where there'd be more accountability for how the money is spent. We quite agree with that.

The undertaking on the part of the Canadian Medical Association and the profession is to be accountable for what it does. Carolyn, you know well there have been many efforts to develop more evidence base for what's going on—the cardiac care network, and waiting list projects. We're working actively in partnership with governments and with other professionals to do that, and that needs to continue. There does also need to be some accountability on the part of the public about how the system is accessed and how it's used. That's the accountability issue.

On the issue of productivity, you're quite right, it's very difficult to measure in the health sector. It tends to get measured by how many operations I do, as opposed to the outcomes. We clearly need to address that. We're on record as making a commitment to work to do that. In order to do that, the research funding that's there and the information base from CIHI will be very important, and we will work with everybody to assure that happens.

The Chair: Dr. Jeans.

Dr. Mary Ellen Jeans: In terms of accountability, it's very interesting that StatsCan and the Canadian Institutes of Health Research don't collect any information related to the outcomes of nursing interventions. So one of the things that would help improve accountability would be to ensure that we are collecting a broad range of data and information about the various components of our health care system.

Certainly nursing is not against efficiency, but we believe the system has perhaps not been driven by the correct set of principles. We highly recommend a health care system—or a health system—based on the principles of primary health care, where there's more public involvement in decision-making about how the system is organized and delivered; where all health professionals serve as a point of access to the system; and where we use the abilities and knowledge of health care professionals in the right place at the right time for the right kinds of problems. We believe that moving to that kind of system where there's more of a patient focus rather than an institution focus, if you like, would in fact be more accountable and would probably result in more efficiency in the system.

Ms. Sharon Sholzberg-Gray: First of all, in terms of the Health Action Lobby, I think it's clear that all 29 members of the Health Action Lobby have mentioned in various briefs—and they sometimes don't repeat the same thing from one year to another—that they are certainly all committed to an accountable health system, one in which everyone involved in providing health care is accountable to the public for providing services in the most efficient, effective way—services of high quality that assure appropriate and positive outcomes. That's why we're looking in a very positive way at the developments with respect to the CIHR—the Canadian Institutes of Health Research—and CIHI's efforts to collect more information. So we're all onside in that area.

I think it's also clear that when we look at the Canadian Institutes of Health Research, we're looking at a variety of research, not only biomedical and clinical research, but health systems research and population health research, to ensure that what we do has a positive impact on the health of Canadians. I think we all say together that in order to have a sustainable health system, funding is just one part—an essential part, but at the same time, we need all of the other parts as well: the research, the information, the human resources, and all of those things.

If I can relate back to the issue of health human resources, my members are the provincial and territorial hospital and health associations, who frankly have contributed to the health human resources problem, but not willingly. Because they were cut back, they ended up laying off nurses, casualizing them, and cutting back in the health system, which in some ways created this. They want to be in a position to restore the situation, and they have indicated to us that health human resources is one of their major issues, which is why we bring it forward in our sustainability framework.

So I think the members of the Health Action Lobby are committed to that same kind of framework in order to create a sustainable system. It needs money, but it also needs all of those other things together.

The Chair: Mr. Gallaway.

Mr. Roger Gallaway (Sarnia—Lambton, Lib.): Thank you, Mr. Chairman.

I have a question for Dr. Scully, and perhaps some others would like to answer it.

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For starters, I must say that I'm from Ontario, so maybe my knowledge is shaped by the press. But having said that, on the discussions or the trial balloons that are being floated in the province of Alberta with respect to what some would suggest is, and what the press is calling, two-tiered health care, I'd like to hear from Dr. Scully the opinion of his association with respect to Mr. Klein's proposal.

And secondly, do you believe Mr. Klein's proposal is being driven by a shortage of cash in the system, or is it being driven by his philosophy?

Dr. Hugh Scully: Thank you.

Mr. Chair, I can't comment on the latter. I don't know Mr. Klein well enough or his personal philosophy well enough to comment on that.

With regard to the initiative that's been taken, as I read very carefully the presentation and discussion so far, it's clear to me that it's still use of public funds for necessary services, now to be both delivered in publicly funded institutions and contracted to private institutions. The concern we would have is that the playing field remain level, that the access in the public system remain good for everybody who needs it, and that there not be a progressive differentiation within the private system for these services.

As far as we can tell in looking at it, there's nothing contrary to the principles of the Canada Health Act here. Certainly it bears very careful watching. I would repeat, the Canadian Medical Association is firmly committed to public funding for necessary medical services, and we work with others to define the whole range if necessary.

So it's a very careful watching brief. Providing that this is focusing on access for everybody and quality is maintained, then it meets the spirit of the act. Once it begins to change, it does not, and that doesn't serve Canadians well. There's no evidence so far that it's done that.

Mr. Roger Gallaway: Okay.

I have one further question to the Canadian Nurses Association, Dr. Jeans.

I live on the border, and every day I hear from nurses who are working on the other side, if I can put it that way. They're probably in the hundreds in the community in which I live, and that's not an exaggeration. Is the turnaround of this problem—rectifying this, returning these people or repatriating some of them to our country—simply a question of underpayment of nurses, or is it also working conditions? Is it that we have not offered enough? Have we ignored the nursing profession in this country, basically?

Dr. Mary Ellen Jeans: It's certainly far more than salaries. As I said, with the ten years we've had of cutbacks in the system, the working conditions of nurses have deteriorated constantly across that ten years. So that's a significant part of it.

But the fact is most of those nurses who've gone south are our younger, recent graduates, because they can't get a full-time job. They can't be integrated into the system in Canada, so their only opportunity is to go south. So we have to have full-time jobs for one thing, and we have to ensure that new graduates can be hired into those jobs to gain their experience in Canada.

We have calls every day, by the way, from nurses who have gone to the States, asking if things are changing, because some of them will come back. If they know they can get a job and if they know the work environment is being restored to something that will support professional practice, many of them will come back.

Mr. Roger Gallaway: I have just one final question. Does your association have any statistics on how many nurses, either in the provinces or nationally, are part-time versus full-time?

Dr. Mary Ellen Jeans: Yes.

Mr. Roger Gallaway: Have we “Wal-Marted” hospitals to the point that everybody is part-time?

Dr. Mary Ellen Jeans: No. We have about 250,000 practising nurses in Canada, and 50% of them do have full-time jobs. The other 50% do not. And of that 50%, half work on a casual basis. What that means is they have no benefits, and they may work in five different hospitals, which is completely unsafe.

If you think about an emergency room in a teaching hospital compared to an emergency room in a community hospital, the nature of the clients coming to that emergency room is different, the physical layout is different, and the team they work with—and it's critical that they work as part of a team—is made up of different people.

So it's really a huge challenge to these young women and men who are trying to carve out a career by working in four or five different places. And it's not safe for the public.

Mr. Roger Gallaway: Okay. Thank you.

Thank you, Mr. Chair.

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The Chair: Thank you, Mr. Gallaway.

Mr. Pillitteri, followed by Mr. Nystrom and Mr. Brison.

Mr. Gary Pillitteri (Niagara Falls, Lib.): Thank you, Mr. Chair. It's just short.

Dr. Jeans, in your presentation this morning you mentioned some countries. This is sometimes a little upsetting to me, sitting here so many years. It's a little upsetting to me when you mention that in countries such as Africa, mothers get visits at home. Let me tell you where I'm coming from, and see if you can tie this up.

When you take a look at Canada, we spend better than 10% of GDP on health care. Look at all of the European countries—I'm not going to even mention the Third World countries—where they spend less than us. In Canada we have one of the highest per-capita incomes in relation to GDP in the world, and we allocate almost 10%. When we take a look, the only country that spends more than us is south of the border, the United States. They're spending anywhere between 16% and 20% of the GDP on medicare. Where do we draw the line? Is this actually allocation rather than how much we spend in the system? That's one part.

The other part is the cash component in transfer payments. It's increasing from $11.5 billion to $13 billion, and eventually to $14 billion and $15 billion a year. But also increasing is the transfer of points to the provinces. Are you making the same representation to the provinces? Are you getting your fair share from the provinces? As we are increasing the cash component, we're also transferring points to the provinces. Are you getting that portion from the provinces? Do you have any follow-up on what the provinces are transferring to you into the medicare system, since they deliver the system?

Thank you, Mr. Chair.

Dr. Mary Ellen Jeans: I'll address the first part of your question. There is significant evidence that allocating funding for public health, health promotion, and disease prevention programs has enormous benefits in terms of the overall health of the population. Part of it is allocation. I'm not suggesting that you need new money to do what is a basic public health service to prevent chronic health problems from developing in newborns and long-term health problems.

The other thing I would say is we don't spend 10% on health. We spend 9% or even slightly less. But all I'm talking about is the need to address early childhood health and development, which saves money down the road. So it's a question of allocation and the political will to distribute the money in a different way.

Ms. Sharon Sholzberg-Gray: Could I answer the second part?

The Chair: Sure.

Ms. Sharon Sholzberg-Gray: First of all, just to echo Mary Ellen, we do spend 9% of GDP on health, and that includes, remember, the private sector spending. In terms of public sector spending, it's only 6.5%. So that all has to be put into perspective. We're number five now amongst OECD countries, no longer number two, in our spending levels. It's always good to remind ourselves of where we've come in efficiency and effectiveness.

Second, I'd like to respond on the issue of transfers to the provinces and the fact that the provinces very rarely give credit to the federal government for the tax point transfers, which started in 1977, when we switched to block funding and to established programs financing.

Our association, the Canadian Healthcare Association, certainly makes available to all of our provincial and territorial members the total transfers to the provinces for health, post-secondary education, and social services. I'd note that the potential $15 billion cash floor that's going to come in in 2003 covers not only health but those other parts of the transfer. We show our provincial members all of the transfers, including the tax point transfer and the cash, and I'd note that it's more than is often said in the realm of political rhetoric.

But even assuming the tax points and the cash, we're saying that for the federal government to be a major player in determining the future health system, its percentage of the health care budget has to be larger. But we do give credit for those tax points. In fact HEAL has always done that, has always recognized it.

The Chair: Dr. Scully.

Dr. Hugh Scully: Thank you, Mr. Chairman.

It's important to recognize that within the CHST, about 41% is for health. So it's not all coming to health as that transfer is made. Federally, nine cents on the dollar is being spent on health—a dramatic drop from 50%, going back twenty years ago.

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Yes, the provinces are spending more on health; that's been clearly tracked. In relative terms, over the last number of years they've spent more than the federal government has on health. One of the issues here is to redress the balance so there's a more equitable distribution.

The final comment I would make relative to comparison with other OECD countries is that the commitment of the Canada Health Act in this country is to fund necessary medical services from the public purse, which is unlike the balance in all of the other countries to which you've referred. If we're going to do that, if we're going to maintain that standard, then there has to be a continued commitment by both the federal and the provincial governments to address that.

The Chair: Any further comments?

Okay, we'll go to Mr. Nystrom for a seven-minute round.

Mr. Lorne Nystrom (Regina—Qu'Appelle, NDP): Thank you, Mr. Chair.

I want to welcome everybody here this morning. I see a couple of old friends, Ms. Sholzberg-Gray, Noelle-Dominique Willems, and others.

I want to commend the group for their consistency in the presentations. What really struck me this morning is it's a scary, shocking story you're telling us that there's no more funding into health care. There will be a shortage of 100,000 nurses in a few years, shortage of physicians, problems with dentists and pharmacists, the aging of the population, the federal government share of funding down to nine cents on the dollar compared to 50 cents on the dollar some 25 or 30 years ago. I think that's really quite a shocking story, which we have to be very aware of.

Is the Minister of Health aware of this? Why has nothing happened? Is he aware, for example, of the shortage of physicians? Is he aware we're going to be in a real crisis in terms of nurses? If he is aware of it, what is the problem? Is the problem between the Minister of Finance and the Minister of Health, or is there some other problem that perhaps you can enlighten us on? I wouldn't suspect there would be any kind of a clash between the two of them over any reason, but somewhere along the line there's a problem. Is the Minister of Health not aware, or is the Minister of Finance just trying to hold the Minister of Health back a little bit for some reason?

The Chair: Mr. Scully.

Dr. Hugh Scully: I'm not going into the last arena, Mr. Chairman. But I will comment that both know there is a problem in the health workforce issue; this was brought to their attention—both of them—last year.

With regard to the Honourable Allan Rock, he chaired the meeting last week, which was co-chaired by the minister from P.E.I., and there were others present. I think their awareness of the situation is much greater than it was even at the meeting in P.E.I. earlier in the year. The commitment on the part of all was to continue to work with the health organizations—with the nurses, the physicians, the other professionals, the pharmacists, the dentists—to try to address the issue. My sense of it was optimism coming out of the meeting that we are going to realize some progress and begin to address that shortfall over the course of the early part of this next year.

Mr. Lorne Nystrom: Thank you.

The Chair: Does anybody else want to comment on that one?

Dr. Jeff Poston: I'd just like to add, of course, that the government has hosted two national conferences—one on pharmacare and one on home care—to gain further evidence and further information about the scope and the implications of the issues, of the lack of a national pharmacare program and the lack of a home care program. So I think he should be well aware of the issues and the problems.

Mr. Lorne Nystrom: Maybe Ms. Sholzberg-Gray could shed some light on this mystery, the whole Rock-Martin question I'm talking about. I'm not sure you'd have any observations that might be pertinent.

Ms. Sharon Sholzberg-Gray: No, none in that area at all. But I would like to remind people of a comment in the Speech from the Throne talking about the fact that there would be at some future date what was referred to as the next significant investments in health, and it talked about requiring evidence about where they would best be made.

We of course think the evidence is there; namely, we have to make sure that the existing medicare system—hospitals and physician services—are properly funded and stabilized. At the same time, we have to broaden the range of services Canadians have access to so they have access to comparable services wherever they live and so the appropriate care is given at the appropriate time by the appropriate provider.

It's clear to us that those next significant investments have to take place sooner rather than later, so we're somewhat heartened by that line in the Speech from the Throne. I think what we really have to do is work at making sure that line becomes a reality this year, and not a year or two from now.

The Chair: Dr. Jeans.

Dr. Mary Ellen Jeans: I would just like to reinforce the fact that certainly the federal minister is well aware of the problems. We submitted statistical reports as early as two and a half years ago outlining these problems. I would, however, suggest that things are more complicated than one minister. If we need a national strategy to invest in health human resources and support this, I would ask the Honourable Mr. Nystrom to speak to his own provincial Minister of Health, who somehow seems to think nurses are a group of oppressed women reacting to some power beyond their control.

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I'm not convinced that all the federal or the provincial ministers truly understand the link between the number and quality of the nursing workforce and the kind of care Canadians are receiving.

Mr. Lorne Nystrom: I've spoken to our provincial minister. I've spoken to her more than once. I was also very supportive and I am very supportive of the Saskatchewan nurses, as the son of the union leader of the nurses in Saskatchewan would tell you.

I want to follow up another question that Senator Gallaway asked here a few minutes ago. Dr. Scully has answered this, but I'd like to ask Dr. Jeans and others. Our old friend Ralph Klein—do you think he is violating the Canada Health Act in terms of his vision for a two-tier health system and privatizing health care in this country? This is a big issue. I'm starting to get calls from my constituents about it, from nurses about it, from others about it in Saskatchewan. Is he in violation of the Canada Health Act in terms of what he is doing?

Dr. Scully has answered the question and he seemed to be a little bit hesitant on some of the things he said. I'd like to ask the same question now of Dr. Jeans and others, and perhaps Ms. Sholzberg-Gray as well.

Dr. Mary Ellen Jeans: I'm not a lawyer.

Mr. Lorne Nystrom: That's to your benefit.

Dr. Mary Ellen Jeans: I'm not sure. All I can say is I don't know if he's in a legal situation in terms of the Canada Health Act yet. But I will say that CNA is completely supportive of a publicly funded health care system and we're very aware of evidence that when there are two levels, private and public, the quality of health care across both will deteriorate, because the private system will obviously try to do things at the lowest possible cost in order to either make a profit or meet certain budgetary targets. The situation in countries where these kinds of things co-exist gives us no reason to want to go down that road. So as an association, we are not supportive of what's happening in Alberta.

Ms. Sharon Sholzberg-Gray: First of all, we have to distinguish between public funding and—

Mr. Lorne Nystrom: Miss Gray is a lawyer, I understand.

Ms. Sharon Sholzberg-Gray: We'd want to distinguish between public and private funding and delivery. We would ask, if the Government of Alberta feels that it's cut back the hospital system excessively—and the evidence is that it has, or it wouldn't have to look at buying services from a private hospital—why the new reinvestment of funds wouldn't go to existing non-profit hospitals.

One could also ask a few other questions; namely, how is it if the hospital was really needed it was sold at a bargain basement price—it was originally a non-profit hospital, remember—to a private sector company? Now, of course, the Government of Alberta doesn't want to pay for bricks and mortar. Well, of course it paid for the bricks and mortar originally. Those are questions that could be asked.

Another very significant question is that if you have a full-service hospital providing services in the private sector and it's doing things like hip replacements that require an awful lot of follow-up, care, and rehabilitation, or might have complications, who pays for those complications and follow-up activities? I gather, of course, the non-profit hospital or services that might be across the street.

So there are a lot questions one has to ask about whether one really can save money by doing that kind of thing. As to whether it actually contravenes the Canada Health Act, we'd have to look at what is in the final legislation in Alberta. But my preliminary guess would be that, unfortunately, it doesn't. That's why the CHA in its brief called for an evaluation and an analysis of the implications of private delivery of both publicly and privately funded health care services. I think this is something that has to be done.

Private delivery is not new in Canada. We have it, as you know, in the home care side and in long-term care. Somehow Canadians have, until this point, accepted that. Somehow a full-service hospital seems to have crossed a line, obviously, or there wouldn't be all this attention given to it. We think we really have to study that line and make some decisions in the future about how we want our health care system to look. Most Canadians seem to be in favour of non-profit public delivery of medically necessary services.

Mr. Lorne Nystrom: My time is up. I'll turn you over to a disciple of Ralph Klein, Mr. Brison.

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Some hon. members: Oh, oh.

Mr. Scott Brison (Kings—Hants, PC): You were asking a question about the lack of progressiveness with the New Democrats in Saskatchewan. You'll have no such concerns with me or my Progressive Conservative Party.

A voice: They don't exist.

Mr. Scott Brison: That's another issue.

Let's go back to the Alberta situation. Correct me if I'm wrong, but even with what Premier Klein is proposing, it is still a completely publicly funded system. We have some elements of private delivery, but it is still a 100% publicly funded, single-payer system. Is that correct?

Ms. Sharon Sholzberg-Gray: That's only for those things who are part of the Canada Health Act. Obviously, as I've alluded to before, there are an awful lot of publicly funded non-hospital services in this country that are provided in the private sector.

Mr. Scott Brison: Sure, but for instance in Toronto the Shouldice Clinic provides a very specific service, and apparently it is doing very well. How many years has this Shouldice Clinic been there?

Dr. Mary Ellen Jeans: It certainly preceded our publicly funded system.

Ms. Sharon Sholzberg-Gray: It has been there since 1945.

Mr. Scott Brison: So there is some history relative to specific service provision.

The Chair: Did you want to comment?

Dr. Hugh Scully: With regard to your question, as far as we know, so far the contracting is with public dollars into the private institutions. So the answer to the Honourable Mr. Nystrom's question is “not yet”.

The fundamental issue that hasn't been addressed is whether the capacity in the publicly funded institutions has been maximized. I don't know the answer to that, but that certainly needs to be addressed.

The Shouldice Clinic is freestanding. I would point out that 99% of physician payment in this country is public; 1% is boutique and other. The Shouldice Clinic has been a freestanding, grandfathered situation for a long time, and it has many international patients as well as Canadian patients.

Mr. Scott Brison: If we wear blinders and ignore these types of opportunities and requirements that are necessary in order for our health care system to be competitive, don't we run the risk that we're effectively going to have a two-tier health care system but people are going to take Canadian money and buy those services outside of the country and contribute more Canadian money to external centres of excellence, for instance those in the U.S.? Aren't we running a real risk if we're not very careful in responding to the real needs and not simply to narrow philosophical constraints?

Dr. Hugh Scully: There are people who have gone to the United States for their care, including some premiers. That is an issue where there has been insufficient public funding for cancer care and other kinds of care, as you know very well.

The challenge in this country is to maintain the public system and to have a healthy workforce generally and therefore be competitive. The fundamental principle is equity in access, not opportunity on the basis of ability to pay.

Mr. Scott Brison: With regard to Mr. Nystrom's question about the shortage of doctors and nurses, I do have some concern that both the federal minister and the provincial ministers have seemed in the past to really not recognize that problem, and I'm glad to hear that perhaps there's a bit of conversion happening in that sense.

My concern is relative to the difference between rural and urban areas in Canada. I believe there are very different problems faced by rural communities and urban communities in terms of maintaining doctors and nurses, and that's also true regionally. If you could reflect a little bit on some of the regional and rural-urban nuances and differences for both doctors and nurses, I would appreciate that.

Dr. Hugh Scully: To address the physician aspect of it, the point you make is quite valid. When one looks at the reasons people stay where they are or go to the more rural and remote areas, the first is professional opportunity. Are the services there that they need to deliver care? I think that pertains equally to a physician, a nurse, or another health professional. The problem is that because of the cuts, in many instances they have not been there.

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The other reason is a professional support system, working in teams—absolutely, support the notion of working in teams. There's work for everybody. That also hasn't been supported adequately, and we need to address that.

There's also the issue of continuing education and the opportunity to do that. If you're on call seven days a week for every week of the year, you simply don't have the time to do that.

The recruitment strategies that have been successful in the United States and elsewhere, and which happily are now being used more often in this country, address the professional needs first—that is, the environment in which the practice is taking place and the professionals who are there to work as a team.

Secondly, it addresses the personal aspects. Many physicians, nurses, and other health professionals are married. There are many two-income families. Of the physicians, 46% of those who are under the age of 35 are female, and two-thirds of them are married to other professionals. So if you want to recruit the female physician, there has to be an opportunity for the spouse, or why would she even think of moving? These measures are very positive incentives. They are not coercive measures, which simply don't work.

Then there's the education for kids and recreation. Then there's money—that is, the amount of money, tax strategies, and so on.

A very important aspect, which was brought up earlier, is the increasing cost of professional education. The debt load of medical students coming out today is in the range of $100,000. That's a crippling load. We do need to address that.

Mr. Scott Brison: What about the issue of licensing? I've been told that a number of foreign licensed professionals are facing a lot of difficulty in getting their Canadian papers in order to practise in some of these remote areas, for instance.

Dr. Hugh Scully: There's no evidence that the proportion of international graduates in remote areas is appreciably different on average across the country. In some provinces it is. In Newfoundland and Saskatchewan in particular that has been the case. What has always been consistent is what is safe for the public and the quality of care they get. I recommended that there should be an increase in the post-graduate complement of training positions, and one of the things that would allow us to do is to evaluate more qualified—and I mean people who do pass the academic test—international graduates in order for them to get a licence to practise in whatever setting they're needed.

The Chair: Dr. Jeans.

Dr. Mary Ellen Jeans: I'd just like to respond briefly. In good times, when we have an adequate number of nurses in the health system, we do not experience shortages in the north. When there's a shortage of nurses generally across the country, it's much more exacerbated in rural and northern areas than it is in urban areas.

The other thing I would say, in addition to what Dr. Scully has said, is that many nurses are attracted to practise in these areas because they can practise much more professionally and with more independence. They can practise to the full scope of their knowledge, for example. But there are huge challenges for nurses and physicians in these areas, and I think as a country we need to come up with some doable, creative plans that would ensure that our citizens in remote and rural areas do get services and that health professionals maybe do some sort of rotation through some of these areas. I would agree with Dr. Scully that a team approach would make for a much better quality of care and a much better experience for the health care professionals.

The Chair: This will be your last question, Mr. Brison.

Mr. Scott Brison: We've been told by some representatives of the fundraising arm of some of the hospitals that tax issues play a role. In the U.S., if one contributes publicly traded shares to charities, there are no capital gains taxes on those publicly traded shares, and that has made a big difference. In Canada it has been reduced somewhat, but we still have a long way to go to have effectively a zero inclusion rate on that. That has affected the ability of hospitals to raise funds, as well as universities and endowments, in order to create those critical-mass opportunities in terms of research and that sort of thing. I'd appreciate your feedback on that.

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As part of the same question, recognizing that the tax issue is not what necessarily draws professionals, nurses or doctors, to the U.S., to what extent does it have the capacity to keep them when a doctor or a nurse in Seattle, say, at $60,000, is paying 28% of their income in income tax, whereas in Vancouver they're paying 51%?

The Chair: Dr. Scully.

Dr. Hugh Scully: Thank you, Mr. Chair.

To address the latter issue, there's no question that taxation policies and what you have in pocket at the end of the day are important issues. That applies to many areas of the brain drain to the United States, as you know. It is a great concern and I think a very legitimate one. Let me say that as somebody who pays a lot of tax, I'm very much in support of tax reduction. That is one of the strategies I think we need to move forward on in a shared way as we do go ahead.

In terms of the endowment, having been the chief of staff at the Toronto General Hospital, I can certainly support what you're saying in terms of the difficulty in raising funds. I would hope that as we explore tax policy and the recognition of legitimate donations for research purposes and education there's a more generous recognition of that.

The Chair: Dr. Jeans.

Dr. Mary Ellen Jeans: I'd just like to say that the tax issue isn't quite as prominent for nurses because they're not considered high-income earners. However, I would like to avoid getting into a debate about taxes versus investing in health care.

For myself and I think most of my colleagues here today, we're here to ask you to advise the finance minister that there is still some urgent work to be done in health care in this country, and if we don't do it now, it could well be too late. By “too late”, I mean that we're going down the privatization road, which the Canadian public does not support. It's not a value of Canadians to privatize health care, to make it only for the rich to access while the poor will put up with whatever crumbs you're going to throw at them.

I just can't emphasize enough that what we're here for today is to get your support to advise the minister to finish the job in restoring—not adding to, but restoring—health care to what it was five or six years ago.

The Chair: Dr. Poston.

Dr. Jeff Poston: I'd just like to add something on the health human resources issue. We really have to start to invest again in growing our health human resources in Canada. One of the factors that's affecting health human resources shortages is that this is a worldwide shortage. There is a shortage of pharmacists in pretty well every western developed country. Australia is perhaps the only place where they seem to be in balance at the moment.

It's certainly going to become increasingly competitive in terms of hiring health care professionals if they're qualified overseas, and it's getting more and more difficult to do that. We really have to start to invest again in our own system, to build our own group of health human resources—pharmacists, physicians, nurses, dentists—because recruiting overseas is certainly going to be a very short-term strategy. It's going to become increasingly competitive.

The Chair: Thank you, Dr. Poston.

On behalf of the committee, I'd like to thank the panel. As always, this health care roundtable is one of the most interesting ones in the pre-budget consultation hearings. You always make a very strong case for investment in health care.

You can rest assured that this committee is quite sensitive to the issue, because we're driven essentially by one major goal—that is, how do you improve the quality of life for Canadians? How do you improve their standard of living? So in regard to anything that speaks to or adds to that particular ultimate goal, we are, of course, quite supportive.

Also, as individuals who have to take care of the taxpayer, we're concerned about accountability, sustainability, and all the issues that are important to Canadians.

You've certainly, as always, added great value to the debate as to where the surplus should go. On behalf of the committee, I would like to express to you our sincerest gratitude.

The meeting is adjourned.