BRIEF FROM THE ASSOCIATION OF FACULTIES OF MEDICINE OF CANADA

Meeting the evolving healthcare needs of Canadians

The Canadian media is replete with claims that the Canadian healthcare system is in crisis – ballooning healthcare costs, doctor shortages, and wait times are all identified as major problems facing our system. There is little denying these challenges – provinces are struggling with the realities of delivering timely, high-quality services to an ever-aging population in a time of fiscal restraint.  While it is tempting to focus our energies on immediate solutions to these problems, sustainable solutions require a focus on upstream factors.  In this brief, AFMC makes three recommendations to the federal government, all with an eye towards ensuring that our healthcare system places the needs of Canadians at its heart.  More specifically, we recommend federal investments in a national health human resources data and analysis centre to facilitate evidence-based HHR planning in Canada, the creation of a medical education opportunities fund to increase diversity among medical students and our physician workforce, and increased investments in Canadian health and biomedical research to fuel the discoveries of tomorrow.

Investing in Health Human Resource (HHR) Planning

Canada rates very poorly on the physician supply indicator, ranking 15^th out of 16 OECD nations in 2008 with respect to its doctor-to-population ratio[i]. According to Statistics Canada, “in 2010, more than one quarter of those aged 20 to 34 (27%) were without a regular medical doctor" and “just over half of those without a regular medical doctor (53%) had tried unsuccessfully to find one. Among these, 40% said that doctors in their area were not taking new patients, 31% said that their doctor had retired or left the area and 27% said that no doctors were available in their area”[ii].

Canada’s poor international standing on physician supply and the large number of people without family doctors are, in part, a legacy of our past. In the late 1980’s and early 1990’s, it was thought by many that Canada was facing a pending oversupply of physicians. As a result, entry level medical school class sizes were scaled backed. In 1997, 1,577 students entered medical school compared to 1,812 in 1985 - a 13% reduction.

Over the past decade, faculties of medicine and provincial-territorial governments have taken great strides to close Canada’s physician supply gap. Increased MD program class sizes have resulted in 7,557 more students entering medical school since 1997 than would have entered if the 1997 entry levels had remained in effect. In total, 28,582 medical students have entered Canada’s faculties of medicine since 1997.

While increasing the number of first-year admissions to Canadian medical schools will have a positive effect on supply, the AFMC believes that more co-ordinated, national HHR planning must be done in order to ensure that Canada trains not only the right number of physicians, but also the right types of physicians.  For example, meeting the changing needs of Canadian society will likely require more physicians trained in the care of the elderly, and perhaps fewer that care for children, given current demographic trends. Establishing national targets is critical, and requires more than simply adjusting admission numbers; Canada needs a more robust and co-ordinated national health human resource planning process, one which factors in physicians as well as other health professionals not just doctors, their evolving scopes of practice, and the changing healthcare needs of Canadians.

Numerous federal bodies play important roles in HHR planning, including Health Canada’s HHR Strategies Division. Agencies like Statistics Canada and the Canadian Institute for Health Information work diligently to deliver timely, relevant health data. Federal, provincial and territorial governments endeavour to coordinate their health care planning efforts through bodies like the Advisory Committee on Health Delivery and Human Resources. Professional medical organizations do likewise through the Canadian Medical Forum.

In addition, HHR conferences are held in Canada each year. A variety of organizations host important HHR conferences that promote knowledge exchange. These conferences foster improved understanding of issues as wide-ranging as Aboriginal healthcare, recruitment and retention and healthy work places.

Reflecting on the collaborative nature of healthcare delivery, we must ask ourselves if our HHR planning efforts have been well coordinated. Unfortunately, one is left with the impression that our efforts are fragmented. Our common goals and objectives appear divided.

Without undervaluing the important HHR planning efforts that are underway in Canada, AFMC continues to recommend the establishment of a national health human resources data and analysis centre. Our efforts to see this project realized lead to the first recommendation contained in the June 2010 Report of the Standing Committee on Health titled Promoting Innovative Solutions to Health Human Resources Challenges, which recommended “establishing a new arm’s length national observatory on health human resources with a broad-based membership that would promote research and data collection on HHR; serve as an effective knowledge translation mechanism; and identify key priorities for future research”.

The proposed centre would provide a formal structure for the collection and analysis of Canada’s disparate data sets, the collection of data where needed, and would serve as a resource to governments, federal and provincial, in matters of policy planning for health human resources.  Just as diverse healthcare providers work together to care for patients, the centre will bring together care givers, patients, federal, provincial and territorial governments, managers, researchers and other stakeholders to analyze data, make evidence-based recommendations and build consensus around forward-looking strategies.

As a first step in the realization of this project, AFMC is proposing that it form a secretariat for the initiative and hold a series of national, regional and provincial consultations which would culminate in an actionable business plan, including budget, for the centre. The anticipated cost for this work is $600,000 and would be complete within 2 years.

Fostering a Diverse Physician Workforce – Medical Education Opportunities Fund

Canada’s diversity is multifaceted and remarkable. Our people live in small communities within the Arctic Circle, mountain villages in the Rockies, farm communities, densely populated cities, harbour villages and countless other settings across the nation. Our people are equally diverse in terms of cultural and ethnic origin; Indigenous populations have been joined by migratory waves from Europe, the Far East, Africa and all corners of the globe. Our history and geography make us, arguably, the most diverse nation on the planet.

Canada’s faculties of medicine are taking steps to foster a physician workforce that better reflects our population and is well-equipped to serve its diverse needs. As a start, we are beginning to measure how our medical students compare to the Canadian population across various diversity dimensions. In terms of socioeconomic status, while medical students come from all family income categories, they are much more likely to come from higher-income families; almost 45% of medical students report coming from families with an annual income of $100,000 or more, a group which represents about 26% of all Canadians. In terms of visible minority distributions among medical students, while all visible minority groups are represented among medical students, Black, Filipino and Latin American peoples tend to be relatively less present among the medical student population. Canada’s Indigenous population is also significantly under-represented in both medical school and the medical profession. 

In its recent report on the Future of Medical Education in Canada, the AFMC acknowledged that “Faculties of Medicine must recruit, select, and support a representative mix of medical students…This will involve, for example, addressing perceived and real barriers to medical education, such as the high debt loads of medical graduates.” Canada’s Faculties of Medicine are determined to take positive steps to make a career in medicine possible for all Canadians, to ensure that Canada’s physician workforce is well prepared to provide appropriate care to our diverse population, and to increase diversity within the profession. 

The AFMC recommends the creation of a Medical Education Opportunities Fund (The Fund) that will increase diversity among applicants to medical school, and ultimately, Canada’s physician workforce. 

The Medical Education Opportunities Fund will subsidize three activities: 1) pipeline programs to inspire and enable talented high school and undergraduate students from under-represented groups to pursue careers in medicine and in health-related research and 2) a bursary program which will dramatically reduce the costs of attending medical school for Canadians from low socio-economic strata and other disadvantaged groups, and 3) databases to better understand the demographic and other characteristic of Canadian medical students.

A portion of the Medical Education Opportunities Fund will be awarded to faculties of medicine or provincial consortiums of schools, on a competitive basis, to create pipeline programs to encourage under-represented groups to apply to medical school.  A portion of the pipeline funding would be specifically earmarked for programs targeting Indigenous students and the unique challenges they face in the application process. These will also require Indigenous Physicians Association of Canada’s participation as a partner to their application. These programs could include, but not be limited to, (a) summer health science enrichment programs for undergraduate students who have completed their first or second year in university, or who are graduating from high school and have been accepted into a Canadian university to help build their knowledge base and academic skills for success in a medical program, (b) programs to expose students to the world of health and biomedical research (c) mentoring experiences with physicians from under-represented communities, (d) opportunities for high school students to participate in summer health sciences enrichment programs and research projects with health and biomedical researchers, and (e) bursaries to help students from under-represented communities defray the costs of tuition for their first undergraduate degree.

The centrepiece of the Medical Education Opportunities Fund will be the awarding of full tuition and living expense bursaries to successful Canadian applicants to medical school from designated under-represented groups. Students applying for these bursaries will be assessed by means of a financial aid and social capital point system.  Applicant background information to be included for assessment will include; familial financial background and applicant social background factors such as whether the applicant is a first generation family member to attend university. These tuition bursaries will be renewed for each medical school year contingent on the successful completion of the previous year.  This central component of the Medical Education Opportunities Fund will make the possibility of a career in medicine a reality for hundreds of Canadians for whom the costs of medical school are currently a very real barrier.

In order to seriously address the issue of diversity in our medical schools, faculties of medicine require more information than they currently have regarding their current students and applicants.  A final component of the Medical Education Opportunities Fund will be the creation of a national database of demographic characteristics of applicants and registrants to medical school in Canada, as well as the development and implementation of policy, protocol and procedures for the respectful and ethical collection, protection, use and dissemination of data from Indigenous students who are entering Canadian medical schools. These two linked data collection exercises will allow faculties of medicine to better understand where they are in terms of diversity, create targets, and evaluate the effectiveness of the Fund.

In order to fund the pipeline programs, award up to 180 new 4-year bursaries per year, and collect the necessary data to evaluate the fund’s impact, an investment of $6.5M will be required in the first year, $10.5M in the second year, $14.5M in the third year.  The fund would reach a steady-state cost of $18.5M in subsequent years. Bursaries will be proportionally allocated across all 17 faculties of medicine, and have been costed based on actual tuition fees for each faculty of medicine as well as individual provincial cost of living expenses, as determined by each provinces provincial loans program.

Investing in Research to Meet the Needs of Canadians

The AFMC represents over 12,000 health researchers from all 17 Canadian medical schools.  These Canadian health researchers train over 35,000 graduate student and postdoctoral (post-PhD) scholars in their laboratories and research programs. They also train the next generation of clinician and non-clinician PhD scientists.  With their trainees, our health researchers comprise the human infrastructure that generates today’s health-related discoveries, providing the foundation for tomorrow’s therapies.

AFMC enthusiastically supports the Government’s efforts to build a knowledge-based economy. Health research is indeed one of the key sectors of Canada’s knowledge economy. Investments in university-based health research provide a foundation for generating innovation and new knowledge that translates into intellectual property and more potent, cost-effective therapies.  With the major pharmaceutical companies largely withdrawing from discovery research, it is incumbent upon the universities, with the critical support of government, to pursue this fundamental research that will fuel our future prosperity and healthcare.

AFMC also supports the four strategic directions that the CIHR has outlined in its new 5-year strategic plan that are focused on delivering on the promise of translational health research. The major new initiative for CIHR - the Strategy for Patient-Oriented Research (SPOR) - requires new resources to effectively leverage matching resources from provincial, industrial and philanthropic partners. 

We recognize that the Government of Canada, through many successful initiatives, has made unprecedented investments in training new researchers as well as recruiting and retaining bright, successful and experienced investigators to Canada. Support for clinician and non-clinician PhD scientists is critical to the success of the Government’s health research strategy and is required to ensure maximum return on the Government’s recent large investments in health care research personnel and infrastructure. 

CIHR has witnessed unprecedented competition in its recent operating grants programs.  At current funding levels and success rates, which include substantial across-the-board budget reductions to all successful applications, CIHR can currently only support about 4,000 investigator-initiated projects over a 5-year term. Thus less than 1/3 of the potential health research conducted within Canada can be supported by CIHR funds, a situation that represents a lost opportunity to advance much needed knowledge for improved healthcare and healthcare delivery.

AFMC’s recent Research Careers Survey provides a comprehensive overview of the long-term viability of Canada’s health research human infrastructure.  This survey reveals telling vulnerabilities that are largely traceable to the decreasing capacity of CIHR to provide sufficient operating funds to support all of the research that merits funding:

·         An increasingly large proportion of Canada’s heath researchers are in danger of being prematurely driven out of their research activities due to the declining ability of the CIHR open operating grant envelope to keep pace with the significant research capacity that has been created over the past few years.

·         Canada’s health researchers have undergone an unprecedented four-year period of recruitment of graduate students into their research laboratories. 

·         The decreasing ability of CIHR funding to support this research potential is tipping the ability to support trainee research rapidly towards unsustainably and is creating an impenetrable barrier for young researchers to enter into the Canadian health research system.

The AFMC is committed to working with the Government in developing effective models for improved health research funding.  Researchers in Canadian faculties of medicine also have expertise in evaluating new models of grant decision-making and funding partnerships.  Finding good solutions to these complex issues will, however, require considerable time, expertise, effort and support. 

In the interim, AFMC strongly believes that to achieve the goals of the Government of Canada’s Science and Technology Strategy and maximize the return of investments the government has made in the recent years, an immediate increase in the allocation of funds to the CIHR operating grant funding is required in the next budget and for the next five fiscal years.

More specifically, we are proposing an increase of $400 million dollar per year for the CIHR operating grants program to provide sustainability to the Canadian health research system and to ensure that the Canadian health research system achieves the goals of the Government’s health research strategy and maximizes the return on the Government’s research personnel and training investments. 

AFMC understands the significance of the magnitude of this request. An investment of an additional $400 million dollars per year to the CIHR operating grants programs would stabilize operating grant success rates at approximately 34% of submitted grants funded (vs. the most recent rate of 23%) which was the approximate success rate in the late 1990’s and early 2000’s before the Government invested in the highly successful Canada Research Chairs programs, that has added 2000 of the world’s best young health researchers to the Canadian health research system. This increased research capacity will significantly place Canada firmly as one of the world’s strongest health research countries, but only if it is accompanied by a parallel increase in the CIHR operating funds that are essential to allowing these new outstanding researchers to build their research programs.  The $400 million dollar per year request spread across the approximately 18 million Canadian taxpayers represents an investment of $22 dollars per taxpayer. This is an investment we expect that Canadians are willing to make since it will have such a large return on improving their lives, increasing the overall Canadian economy, and long term, in reducing health care costs.