HEAL Committee Meeting

STANDING COMMITTEE ON HEALTH

COMITÉ PERMANENT DE LA SANTÉ

EVIDENCE

[Recorded by Electronic Apparatus]

Thursday, May 13, 1999

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[English]

The Vice-Chair (Mr. Ovid L. Jackson (Bruce—Grey, Lib.)): Good morning, everybody. I would like to call the meeting to order.

I apologize to our guests for the tardiness of some of our members. We did have a vote. This is a two-hour meeting this morning. Since we're starting at 11.30 a.m., I think our maximum end time will be 1.30 p.m.

I understand some of our witnesses, as well as some of our members, may have to leave a little earlier.

Don't feel it's your presentation that makes them leave. They have other responsibilities and different things to do.

We have people from four different departments of Health Canada. We have the ADM, medical services; ADM, home care development; ADM, policy and consultation; and SADM, corporate services.

They are represented by Marie Fortier, associate deputy minister, policy and consultation branch, and assistant deputy minister, home care; she's wearing two hats. We have Phyllis Colvin, director of health policy division, policy and consultation branch; Frank Fedyk, director of health system and policy; Richard Jock, director general of program policy; Robert Lafleur; Orvel Marquardt; and Pauline Bissonnette.

I may have missed someone. I understand Marie Fortier and Robert Lafleur are going to introduce our guests.

We're going to start with our usual five-minute rounds, as was agreed to earlier on. The second round will be five minutes per party as well, alternating between the opposition and the Liberal Party.

I'd like our guests to start. Normally it's between five and ten minutes for presentations. Usually members like to ask a lot of questions, but because the information you give may be of interest and may round out and give us a perspective on your departments, if it's okay with our opposition members you'll have up to 10 minutes each to make your presentations.

Ms. Marie Fortier (Acting Associate Deputy Minister, Policy and Consultation Branch; Assistant Deputy Minister, Home Care Development, Department of Health): Thank you, Mr. Chairman.

[Translation]

Good afternoon, ladies and gentlemen. Thank you for giving me this opportunity to make this presentation to your committee.

[English]

Just to round out the introductions, Mr. Chairman, I'm accompanied by Abby Hoffman, director general of health policy and information directorate; Phyllis Colvin, whom you've introduced already, director of health policy division; Frank Fedyk, director of health system and policy; Linda French, director of federal-provincial relations; and Gweneth Gowenlock, director of communications and consultations for the home care development branch.

I'm indeed wearing two hats here—policy and consultation as well as home care development.

I'll start with a description of the activities and roles of the policy and consultation branch. This branch employs approximately 235 people and manages a budget of $118 million, which is about 6% of the department's budget for 1999-2000. A large portion of this amount, or 70%, is made up of grants and contributions, primarily for the health transition fund, about which I'll say a few words in a moment.

The role of this branch, as the name suggests, is to deliver policy advice to the Minister of Health. In that regard, we provide a corporate function. It's policy advice on the broad range of issues the department is responsible for. Because the policy issues are broad and complex, of course there's considerable interaction not just within the department but also with many other departments, and certainly with the provinces and territories, for obvious reasons, and the non-governmental sector.

The policy and consultation branch is responsible for five main functions—health policy and information; communications and consultation; intergovernmental affairs; international affairs; and strategic planning and review. I'll say a few words about each of these areas.

The health policy and information directorate develops comprehensive policy related to the health system overall. It deals with a broad range of topical issues, such as health system financing, which is Frank's specialty, the long-term sustainability of medicare, access to pharmaceuticals, new reproductive and genetic technologies, tobacco, and a number of other issues.

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This directorate also houses the women's health bureau and the centre of excellence for women's health and research, which help to promote a better understanding of the critical role gender plays in health.

Communications and consultation, another unit in the policy and consultation branch, also provides corporate support to the department in communications analysis, strategy, and advice, and of course supports the minister in his activities.

The overall objective is to ensure that the Canadian public is aware of the issues and programs Health Canada is involved with.

We also have a presence in our regional offices. We have regional offices throughout the country, and in each of those there is a communications officer who deals with more local issues and provides advice to us on matters the department needs to be aware of.

That directorate is also responsible for publications, for the Health Canada website, and for “Health Online”, all of which are gaining popularity as time goes on.

The intergovernmental affairs directorate is the department's focal point for federal-provincial relations. As well, in this directorate there is the health insurance division, which administers the Canada Health Act and monitors adherence to its principles, and works with provinces on these matters, etc.

Intergovernmental affairs is also the home of the health transition fund secretariat. That fund was launched in 1997 with a three-year program and a budget of $150 million. It's a funding program for innovative pilot and evaluation projects that are conducted in partnership. Approved projects must aim to sustain a publicly funded health care system and improve access to services. There are several priority areas—home care, pharmacare, primary care, and integrated health services.

A number of projects have been funded so far. I'll speak about one of them. It is important to note that this has been an extremely successful program. It will wind down sometime toward the end of the fiscal year 2000-01. We will be extending it slightly, not with additional dollars but by moving some of the expenses forward because of what was to some extent a slow start.

A factor that has influenced its success has been the excellent partnership with provinces. From the beginning, a joint management group was put in place, and all decisions were made jointly by provinces and the federal government.

The projects really were a blend of areas and issues that provinces had a keen interest in exploring and testing new ideas around, and they worked within the framework of the four priorities. It's really an enormous source of new knowledge that we're going to draw on as the projects come to a close.

Many of them are just starting up, so even though the money will run out, we still have an awful lot of work to do to learn from these experiences. I know the provinces are also quite interested in how we will analyse the results of the projects and make that information widely available.

One concrete example of a health transition fund project is called From Chaos to Order: Making Sense of Waiting Lists in Canada. This is an issue that Canadians are extremely concerned about, as I'm sure you know.

This is a $2.2 million project that is designed to improve the standardization and management of waiting times for a number of services. Focusing on a limited number of services, it's obviously at the pilot stage. The goal is to develop and test computerized tools that will help decision-makers make the best use of their resources and manage who should be put at the front of a waiting list and on what criteria we can make those decisions.

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It involves 19 partners, including the Canadian Medical Association, the ministries of health in the four western provinces, a number of regional health authorities, the medical associations in those same four provinces, and research institutions throughout the west.

[Translation]

The fourth directorate of the Policy and Consultation Branch is the International Affairs Directorate. Canada is known throughout the world for its health system but, also, many questions having to do with the health sector in Canada impact on other countries. The International Affairs Directorate is thus working at developing international strategies while ensuring the promotion of Canada's interests abroad in the area of health.

We deal mostly with the World Health Organization and its regional offices in Europe and America. For example, one of the matters the International Affairs Directorate is working on with the WHO, together with other domestic stakeholders, within Health Canada and elsewhere, is developing an international convention on the fight against tobacco. That's an important subject for us, here, in Canada, but it's also a very topical issue at the international level.

[English]

The branch's fifth area of responsibility is strategic planning and review. This directorate conducts evaluations, supports business planning, and provides advice to senior management in a variety of areas. It also works to align the department's resources with its strategic goals.

We also have an internal management services directorate that supports branch-specific activities in planning, co-ordination, and branch operations.

Obviously things change, and our branch adjusts as requirements change. Last June, for instance, the minister announced his intention to strengthen the focus on nursing policy in Canada. As a result, we have recruited a person to perform that role.

Just this week the minister announced that the department had appointed an executive director of nursing policy, who will be joining us later this year. Her name is Dr. Judith Shamian, and she will be responsible for advising Health Canada on a number of nursing issues that are of concern at the moment to the nursing profession, to the public, and to the people who manage health systems and health care organizations. She'll be responsible for working closely with the broad nursing community in this area and for developing advice for the department and the minister.

The Vice-Chair (Mr. Ovid Jackson): I hate to interrupt you, but you're getting close to being a little over the 10 minutes. Perhaps you could wrap it up, please. We'd like to have enough time for questions.

Ms. Marie Fortier: Okay. Thank you.

[Translation]

I'll say a few words about the development of home care.

[English]

A year ago we established a group of Health Canada and outside experts to develop plans for the future of home care in Canada, and now 18 people are members of that group. They have been working at defining home care and its role as a substitute for acute hospital care as a way to enable the chronically ill to remain in their homes; as a preventive service that delays the need for long-term-care institutionalization; and as a support for people who wish to die in their own homes.

Home care is a bit of a patchwork. We need to do a lot of work with provinces and with people who are involved in the provision of home care. Particular issues that the group has been working on include: labour issues relating to the paid home care workforce; the concerns of informal caregivers; and the use of telecommunications and other technologies to enhance that sector.

We've held a number of constructive round-table discussions with stakeholders over the past few months, and that has helped define issues surrounding home care. We're working on refining that and clarifying the federal role.

We are just launching with HRDC a labour sector study that will be very useful to the sector. A number of the health transition fund projects, to which I've referred, have focused on home care, and we're going to be learning from that.

I'll stop here, Mr. Chairman, and let my colleagues speak. I'll certainly be happy to answer questions.

The Vice-Chair (Mr. Ovid Jackson): Thank you very much.

Mr. Lafleur, 10 minutes, please.

Mr. Robert S. Lafleur (Senior Assistant Deputy Minister, Corporate Services Branch, Department of Health): Thank you, Mr. Chairman.

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[Translation]

It's a pleasure to be before the committee once again.

[English]

Mr. Chairman, you introduced Pauline Bissonnette, but I would just like to share with the committee her role. She is acting director general of the departmental planning and financial administration.

I also have with me Robert Joubert, the director general of human resources. He is in the audience, as is Marie Williams, the director general of the year 2000 project.

Mr. Chairman, the responsibilities of the branch are essentially twofold. The first is to provide a range of common administrative services across the department in order to support the delivery of Health Canada's programs. The second one is to provide advice and direction in order to support sound management practices and contribute to the efficient utilization of departmental resources.

These responsibilities are currently being performed by some 500 employees across the country, counting both full-time and part-time employees.

Our budget for this fiscal year is $105 million. This includes a $12 million loan for year 2000 adjustments as well as $37 million in capital funds for the department.

The corporate services branch provides core services in key resource areas—namely, internal financial services, services dealing with human resources, and services that support the acquisition and management of physical assets.

In the case of financial services, Mr. Chairman, you may wish to note that we've recently made the transition, in collaboration with 15 other government departments and agencies, to a modern financial and materiel management system using the latest in information technology—namely, SAP, or SAP/R3. This represents a successful conclusion to a two-year effort at Health Canada.

The challenge for this fiscal year will be to maintain the momentum in terms of utilizing the enhanced capabilities of the system to their full potential, eventually implementing full accrual accounting and other financial strategies in line with government-wide objectives.

With to respect human resources, we're working hard to implement the universal classification system that is consistent with the government-wide schedule. In addition, we're now into our second year of implementing the order of the Canadian Human Rights Tribunal regarding employment of visible minorities.

Here, our results are above target. The proportion of departmental employees in each of the employment equity groups now exceeds the proportion available in the labour market. In the case of visible minorities specifically, our proportion now stands at 8.9% as compared with 8.7% in the labour market.

Moreover, we have almost doubled, in just one year, the percentage of visible minorities in the executive group, from 3.6% in April 1998 to 6.8% this year.

In the case of physical assets, we've worked hard to contribute to the environmental sustainability of our physical plants and look forward with great anticipation to the official opening of the Winnipeg laboratories next month. This is the latest and most advanced addition to the world's very small number of level 4 facilities.

In closing, I would like to note that corporate services branch is the project lead for Health Canada's year 2000 effort, and we're working with the rest of government on year 2000 issues, including the development of national contingency plans in the health sector.

We're confident that we are on target and that we will be well positioned to deal with any emergencies in the health sector arising from year 2000 problems, if they should come.

Thank you, Mr. Chairman.

The Vice-Chair (Mr. Ovid Jackson): Thank you very much. You did a good job. You started at 11.45 a.m. and finished at 11.49 a.m.—four minutes.

We'll open a first round of questions.

Oh, we have one more branch.

Mr. Jock, I'm sorry.

Mr. Richard Jock (Director General, Program Policy and Planning Division, Medical Services Branch, Department of Health): Thank you, Mr. Chairman.

I'll give you a bit of a description of the branch in terms of our mission to establish a renewed relationship with first nations and Inuit, one that's based on the transfer of direct health services; that looks to develop a refocused federal role in delivering health services; and that at the same time seeks to improve the health status of first nation and Inuit peoples.

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In terms of the overall direction being pursued by our branch, it is that first nation and Inuit people will have the autonomy and control of their health programs and resources within a timeframe to be determined in consultation with first nation and Inuit people. This hearkens back to the 1979 federal Indian health policy, which recognized that, really, Indian and Inuit communities were in the best position to develop effective responses to their own problems and the programs therefore to respond to those.

I'll give a bit of a description of some of the pathways or ways in which first nations can move to control their health programs.

Pre-eighties, the medical services branch delivered all aspects of the programs, and did so under such direct service mechanisms as personnel. In the early eighties, contribution agreements were developed as fairly prescriptive ways of delivering certain health services at the community level.

For example, community health representatives were the people who were thus employed within first nations communities. The National Native Alcohol and Drug Abuse Program in the early eighties was the first program designed to be managed entirely at the community level.

In the mid-eighties, the transfer approach was developed. A community can move into a pre-transfer stage in which they study their health issues, develop an overall approach, and do needs assessments that can assist them in developing their own plans.

However, in doing our design, we also did not provide for some of the communities that either are very small or do not have the same interest in academic-type endeavours, such as needs assessments. The integrated approach was developed, which enabled communities to assume gradual control of programs rather than take the more dramatic approach, as contained within the transfer process.

The first transfer agreements were signed in 1987. Of course, we have some self-government agreements. The Nisga'a one will be the first one of a comprehensive nature, and will certainly set a precedent for what we will see more and more of.

Our branch strategic directions in terms of transfer of control of health programs are also dependent on a couple of main pillars. While we're considering ways in which first nation and Inuit people can best run the health system, there is still the ongoing responsibility to look at emerging health trends and thus be able to come up with new programming to deal with emerging needs.

So we need to continue to focus on ways of dealing with some of the health inequities that exist among the aboriginal population. At the same time, our long-term success will be dependent on our ability to have a sustainable health system from the point of view of development but also in terms of the plain economics of the health system.

With regard to transfer, there's a pre-planning process, so it's not what would be considered a dump-and-run process. There's the opportunity over a year to study the conditions and circumstances of the community, to put together a plan, and to negotiate further based on that.

Again, it's intended to strengthen and enhance the accountability of chief and council to the community members, ensuring, at the same time, that public health and safety is maintained through mandatory programs that have been developed—for example, communicable disease—and the things that are essential if first nations are to be part of the bigger health scene.

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To give you a bit of a status update, at this point 79% of first nations communities are involved in that control process. Transfer agreements have already been signed by 39%. An additional 15% are in the integrated process that I briefly touched upon, and 25% are involved with pre-transfer planning. So significant numbers of people are involved in assuming various types of control over health systems.

I just want to mention, however, that, thus far, transfer has been limited to community health programs, and non-insured health services are still excluded from the mandates for community delivery. However, that is something we're quickly moving to address.

In terms of moving to sustainable goals, seeing developments that are occurring throughout all of the health jurisdictions in Canada, it's important to look at sustainable development and to look at a health system that's well integrated and co-ordinated within all of the complex jurisdictions that are there and that are, in a sense, more complicated for first nations. We need to be able to lay out a long-term vision of a health financing system that will help people attain their aspirations in a way that is controlled by them, paced by them. We also need to look at the integration at federal-provincial levels as an important element. As well, we need to look at means of optimizing the potential relationships and spinoffs with regard to co-ordinating health and social services together.

I'll give you a brief summary of our community health programs. Community health nursing is of course a main element and a main way by which we deliver services. Certainly the nursing issues that affect first nations are very similar to, and perhaps even a little more complicated than, those faced in other jurisdictions, and are also well publicized at this point.

Health education and nutrition are important. There is an increasing emphasis on prenatal nutrition.

Community health representatives are paraprofessionals trained at the community level, and are important intermediaries involved in health promotion efforts. The National Native Alcohol and Drug Abuse Program is a very important and critical program dealing with one of the elements that certainly affects the future development of a range of people.

Regarding treatment services in some areas, our nurses provide expanded services, because essentially we're the only health providers in the area. There is an expanded function for nurses, who do many of the same types of services as physicians in southern communities. So we do have a very important role there for a smaller number of communities, probably 100 out of the 600 communities nationally.

Communicable disease control, particularly with regard to tuberculosis, still requires ongoing maintenance and vigilance.

Environmental health is provided through a combination of officers plus the community health representatives.

I'll just touch base on dental services. They are provided in select jurisdictions.

Community mental health is provided through such programs as Brighter Futures and Building Healthy Communities. They are designed by each individual community.

Aboriginal Head Start has begun in the last year and is available in a select number of communities. It's not universal.

Health information systems have been developed and will be implemented.

Non-insured health benefits represents approximately $500 million of our budget. It provides overall coverage in drugs, dental, and vision care. It's done through a national system of real-time adjudication. It is certainly a success within our branch in terms of management and response to client needs.

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I've included here some statistics for you in terms of some of the situations faced by first nations. Certainly the life expectancy is quite at variance with the general population. Injury is a major factor, as is chronic disease, including diabetes. I would say youth suicide is a major concern.

With that, I'll stop.

The Vice-Chair (Mr. Ovid Jackson): Thank you very much, Mr. Jock.

As I said before, we'll go to the first round.

John, do you want to start, since you have to leave, or are you going to defer to Dr. Martin?

Mr. John Cummins (Delta—South Richmond, Ref.): I want to thank Dr. Martin for giving me the opportunity to raise a question here this morning.

The structure of this department boggles the mind, but I'm sure somebody down there can answer the question I have.

Last week I attended this committee, and I was asking questions about the antimalarial drug mefloquine. As you know, the Auditor General recently issued a report on that drug.

In testimony before the committee, Ms. Pound of your department said the following:

DND did submit [adverse reaction reports] to us, and we did see them also when the manufacturer made the formal application for [their] approval of this drug in Canada.

I'd like to know whether you concur with Ms. Pound's statement last week. Is that an accurate statement?

Ms. Marie Fortier: I can't answer that question. I have no doubt that what she said is what she knows about the facts, but I can't answer that. If there's a particular point you want clarified, we can ask for a written confirmation.

Mr. John Cummins: My point is, that statement of hers is in direct contradiction of the facts as reported by the Auditor General and the facts as I understand them. I'll quote the Auditor General: There was a failure by Health Canada to monitor the study. That's a fact.

The Auditor General also said that it was not, however, until October 1994, when the use of the drug by Canadian soldiers in Somalia became an issue, that Health Canada asked the manufacturer for copies of the records on 69,000 doses of mefloquine provided to National Defence in 1992. The manufacturer did not have any such records, although the study protocol called for them to be provided to the manufacturer every six months. When National Defence could not provide the information, Health Canada took no action.

That is to say, Health Canada never bothered to enquire about missing adverse reaction reports from DND, as required under the safety monitoring study, until there were media reports about the problem in October of 1994, nearly two years after the department had licensed the drug.

Is that standard practice for the health protection branch? You're associate deputy minister, and you ought to be able to answer that question. Is that standard practice?

Ms. Marie Fortier: I appreciate the—

The Vice-Chair (Mr. Ovid Jackson): If I may interrupt, I'd like to point out a couple of things.

First, I hope the questioner addresses questions to the chair and the answers come through the chair as well so that we don't have just a dialogue between the two factions.

We do have people from the department; they're not necessarily politicians.

In the cases where you don't actually know or you can't have the information, you may have to get it from another source. That would be the approach. It should be in writing for the whole committee.

But go ahead.

Ms. Marie Fortier: That was going to be my answer.

I'm afraid I can't comment any further. I don't have the information, and I'll be happy to ask my colleagues from the health protection branch to supply that information.

The Vice-Chair (Mr. Ovid Jackson): So that will be supplied to the best of your ability. Please make a note of it.

John, you still have some time, I think.

Mr. John Cummins: Do you want to go ahead?

Mr. Keith Martin (Esquimalt—Juan de Fuca, Ref.): Yes, please.

Mr. Chair, Mr. Cummins has given me the rest of his time.

The Vice-Chair (Mr. Ovid Jackson): Okay.

Mr. Keith Martin: Thank you all for coming here today. We could spend more than a day on the questions that arise, but I'll restrict myself to two sections.

The first one deals with something close to my heart.

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Mr. Jock, I appreciate the intervention you made, but while it's nice on paper, I would suggest to you that what is happening on paper is completely disassociated from what's happening in the real world on the reserves.

When you have situations where children with open, seeping wounds hug their drunk parents' legs at ten o'clock in the morning on a reserve; where people were raped or murdered; where suicide exists; where you have chiefs in the same reserve pocketing a substantial amount of the money that was earmarked for health care to buy new Ski-Doos and trucks for himself and his buddies, then how, sir, can we possibly get the money that is earmarked for health care to help these people? How are you going to get the accountability that is in here? It would be nice, but it's simply not happening on the ground. Who is going to actually be the caregivers for these people?

The nurses who work up in these areas, as you and I both know, are heroes. In my view, they are heroes. They commit incredible numbers of heroic acts all the time that we never know about.

Who is going to give this caregiving to these people when in a reserve with a 50% unemployment rate, we can't even find somebody, who would be paid $20 an hour, to answer the phones? Who is going to take care of these people?

This is more than just an inequity. As we know, the situation that is occurring on these reserves has not improved in many of them. In some it has, but in many of them it has not improved for a very long time.

How are we going to enable these people to be able to stand on their own two feet and be able to be employed—

The Vice-Chair (Mr. Ovid Jackson): Dr. Martin, technically you're out of time, but because the question was a follow-up question, the rest of the committee will allow you to—

Mr. Keith Martin: Well, I'll stop there.

The Vice-Chair (Mr. Ovid Jackson): Mr. Jock can answer the question with regard to accountability. Then in the second round you could pursue it further.

You have a couple of minutes, Mr. Jock.

Mr. Richard Jock: First of all, I would say it's not always appropriate to react... There may be individual circumstances that you're aware of. However, without more specific information, I can't really comment.

I do feel that the approach we have developed, which obviously can always use improvement, is one that's designed to develop capacity at the community level, to have ownership, and to provide the resources that enable communities—or ourselves, as the case may be—to deliver those necessary services.

From what I would guess, I would say those communities are probably still under our management, but at this point, I would be guessing to try to figure that out.

In general, the system of accountability that is there due to the developmental process is a much better approach to doing business. I can speak personally to seeing some of those successes. If there are areas of focus, we would be interested in examining those and working on those.

We are also looking at developing institutions to support communities. One of those would be the aboriginal health institute, which would be a way of supporting and dealing with circumstances of great need.

Thank you, Chairman.

The Vice-Chair (Mr. Ovid Jackson): Madam Desjarlais.

Ms. Bev Desjarlais (Churchill, NDP): Thank you, Mr. Chair.

Thank you, everybody, for your presentations.

Mr. Jock, your blood obviously didn't boil quite as much as mine did. The comments from Dr. Martin, I would suggest, sounded to me somewhat like this: “All blacks eat watermelon.” I didn't appreciate the comments that all the parents would be drunk, or that all the chiefs are pocketing the money.

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I can assure you, I would stand behind the chiefs in my riding, which has 31 first nations. Quite frankly, the people in their communities, if there is evidence to convict people of pocketing money, do take people to task if the money isn't being spent properly. I'm quite confident of that.

Rather than hear random statements about all chiefs and all Indian people, I would suggest that if there's a real issue here, they take those people to task, press charges, and go the route. That can happen on first nations communities as well as anywhere else.

So as I said, I'm impressed that your blood didn't boil the way mine did.

In your presentation, Mr. Jock, it mentions the number of first nations people with a high school education—i.e., “37% of on-reserve population have a high school education”.

Is that a completed high school education or are we considering grade 9 or grade 10 as being high school education?

Mr. Richard Jock: Completed.

Ms. Bev Desjarlais: Okay.

Has there been an assessment done as to what are the specific requirements for health care professionals within reservations? I know the royal commission report indicated how many would be needed. Have there been assessments done? Are they part of the process in each community as to what the needs will be—so many physicians, so many physical therapists, so many nurses? Has that been done or is it intended that it be done?

Mr. Richard Jock: In general, as you pointed out, the royal commission did address the number of health professionals. However, one of the values of doing transfers is that you can readily see which professions will be in your community. To me, it gives you a clear view as to what the opportunities are.

For example, if you're from Akwesasne, you'll know that at least six community health nurses will be there. There are dentists in the community. There are administrative positions. There is a whole range of different elements. So that gives you a target.

Ms. Bev Desjarlais: Is it identified ahead of time? Take a first nation with 4,000 or 5,000 people that doesn't have a doctor on site, or knows their population is going to increase this much more. Is there something in place saying to the first nations people that they are going to need this many more nurses, encouraging people from the community to go into those professions? Is anything like that done?

I know we can look now and say, yes, we need six, or we have six now, but is there any type of process in place to identify for the future where the needs are going to be?

Mr. Richard Jock: I have to say, no, not really, although we do fund the National Aboriginal Achievement Foundation to do health careers development. Part of the task of this group is to promote health careers and to do so in a way that perhaps they could be the most uniquely positioned to do so.

So in answer to your question, I would say, no, not really.

Ms. Bev Desjarlais: My time's probably up, so I'll get you on the second round.

The Vice-Chair (Mr. Ovid Jackson): Okay.

Maria.

Ms. Maria Minna (Beaches—East York, Lib.): Thank you.

I have a few questions. I may not get to them all at this time, so I'll come back next round.

The gender and health issue was mentioned earlier, and I know Abby Hoffman is with the centres of excellence that work with that area.

Has there been, or is there being done now, any research with respect to multicultural health? I was talking to a colleague just the other day, and apparently a U.S. study with respect to heart disease has found that black women are not treated the same as other women in terms of heart disease.

Now, that may not be the case in Canada, because we have a different health system, but in terms of multicultural health, and then gender as well within the ethnocultural and multicultural and racial gamut, has there been research done there? Who's looking at that, if anyone?

Ms. Marie Fortier: I think Abby is the best person to answer your question.

Ms. Maria Minna: I thought so.

Ms. Abby Hoffman (Director General, Health Policy Division, Department of Health): As you know, we have this network of five centres of excellence for women's health. Those organizations have both an academic research focus and a strong community development focus.

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In particular, two of the centres, one in Montreal and one situated in Vancouver, which serves the entire B.C. region, actually do quite a bit of work with respect to multicultural health issues.

Now, I would say these are not centres whose focus in terms of their research is biomedical or clinical. It's much more focused on issues of access—

Ms. Maria Minna: That's partly what I'm talking about, yes.

Ms. Abby Hoffman: —by women in multicultural communities to existing health services.

There are a number of projects. I'd be happy to provide you with some more details, if you wish. Those two centres in particular probably have five or six projects in progress right now.

Ms. Maria Minna: Do you know if there are any results from any of those projects, or are they still ongoing?

Ms. Abby Hoffman: I think some of the projects have indeed been completed. I can, through the chair or through the committee, pass some of those reports to you—

Ms. Maria Minna: Yes, I'd like to see some of that.

Ms. Abby Hoffman: —particularly in the case of Montreal. In Vancouver, most of the work is being done with women from south Asian communities, but in Montreal it's a broader sweep of interests. South Asian, Haitian, and Caribbean women, among others, including off-reserve aboriginal women living in the greater Montreal area, are involved in a number of these projects.

I would be happy to pass more information on, if you like.

Ms. Maria Minna: I would appreciate that very much. I think that would be helpful, at least for me, and I know for some of the other members.

With regard to the centres of excellence, I guess what I would like to know is whether there is a great deal of overlap. Is there duplication or research in the same areas? Are they all specializing or centring on specific different areas, specializing in different aspects of health, apart from the odd one, of course, like this one here?

Ms. Abby Hoffman: There's a mix, actually. We've encouraged them to pursue their own individual priorities that make sense for their particular communities.

For example, in Nova Scotia, in the centre that is situated in Halifax but really has commitments for the entire Atlantic region, they're spending a certain amount of their time and energy doing work that pertains to black women in their particular communities. The same applies to various centres across the country.

However, there are some themes that are extremely important that we've encouraged all of them to pursue, particularly around the whole area of health system reform and its impacts on women, both women as users of health care services and women as individuals who work in the health care system, be they in roles as professionals—as nurses or physicians or other practitioners—or as unremunerated caregivers.

So there is, in fact, a research program that cuts across and involves all five of the centres.

The centres' representatives, their lead researchers, get together regularly, at least twice a year for several days, to talk about their projects. There are research team leaders situated in a single centre who actually reach out and have involvement with one or more of the other centres.

So we were, at the outset, trying to build a network of researchers and policy advocates who would use the research findings. I think our view is that this has worked very well.

Ms. Maria Minna: Do I have time for one more question?

The Vice-Chair (Mr. Ovid Jackson): No. We'll get you in during the next round.

Ms. Maria Minna: All right. I was on a roll there.

The Vice-Chair (Mr. Ovid Jackson): I have a couple of quick ones, and then we'll go back to Dr. Martin and alternate back and forth.

Perhaps the answers can come from the medical services branch or the policy consultation branch.

Under the self-government agreements, such as the Nisga'a agreement, how does the federal government ensure the Canada Health Act? How do they enforce the principles of it? Does anybody know?

I'll ask one other question so that I don't interrupt you, because my round starts right now as well.

Recent announcements suggest that the departments are preparing to move into such reproductive technologies as human cloning, genetic technologies, and in vitro fertilization.

Could you bring us up to date on your efforts on those fronts?

• 1220

Ms. Marie Fortier: I think Richard can deal with the first question and Phyllis Colvin can speak to the minister's plans with respect to reproductive and genetic technology.

Mr. Richard Jock: In general, any of the health dollars within the Nisga'a agreement would follow the framework of Canadian law and would also, where federal law does not apply, follow provincial law. So in that context, there are fair constraints in terms of what's possible.

As well, the amounts being transferred are community health programs that, in general, are not affected by the principles of the Canada Health Act, and nor would there be an impact upon the Canada Health Act.

Ms. Phyllis Colvin (Director, Health Policy Division, Policy and Consultation Branch, Department of Health): With respect to reproductive and genetic technologies, as you're aware, this government introduced Bill C-47. It focused on prohibitions, but unfortunately it did not complete the legislative process before the call of the last election.

In the interim there's been reconsideration of how to approach the legislative project. Minister Rock, in particular, has announced his intention to introduce what is called “comprehensive” legislation—in other words, a combination of prohibitions and a regulatory regime—before the end of this calendar year.

In preparing for that, he has initiated consultations with stakeholders. There was a first meeting in that area on March 3. It's expected that a plan will roll out over the spring and summer in order to effect consultations with stakeholders prior to the initiation of legislation in the fall.

The Vice-Chair (Mr. Ovid Jackson): Okay.

Anybody else?

Then we'll go to Dr. Martin or John, whoever wants to go.

Mr. Keith Martin: Thank you, Mr. Chairman. I'm going to split my time with Mr. Cummins.

Mr. Jock, I wouldn't want to imply, in any way, shape, or form, that this affects all aboriginal communities and people. I'm just referring to the ones I have had personal dealings with. I'm sure our common goal is to improve the health and welfare, on and off the reserve, for aboriginal people.

I have two questions. First, would you describe for us what methods of accountability you have to ensure that the funds earmarked for aboriginal health care are going to go for aboriginal health programs? What assurances can I give to grassroots aboriginal people in my community that they will have a say in where that money goes, and will know where that money goes when they ask questions, which they're not getting to ask right now, about where the money goes in the communities?

Secondly, who are going to be the caregivers when, as was articulated before, there's such a lack, unfortunately, of aboriginal people, on and off reserve, to be caregivers under these circumstances? Who will be the caregivers for aboriginal people?

Thank you.

Mr. Richard Jock: There are two forms of accountability. Obviously, if we're the direct-service delivery agent, where we're running the nursing station or whatever, we would have direct accountability. In general, that would be the regional director, and obviously as well through the decision-making structure right up to the minister.

In transfer programs, there is a community health plan that's developed. Yearly financial and program reports are generated. As well, there's a redress or appeal mechanism contained within the agreement, accessible to either community members or the community, to attempt to raise issues of problems in terms of health service delivery through the minister's representatives. Of course the minister himself is also an avenue of redress and appeal.

Mr. Keith Martin: Can they do this anonymously? The reason I'm asking this is that they get hammered on their reserves by the leadership when they start asking questions.

Mr. Richard Jock: I would say that, in general, we don't respond to anonymous items, for obvious reasons.

Mr. Keith Martin: Sorry; I mean anonymous to the leadership.

• 1225

Mr. Richard Jock: Yes, we would undertake to protect that person's identity.

Mr. Keith Martin: Thank you.

The Vice-Chair (Mr. Ovid Jackson): John.

Mr. John Cummins: Thank you.

Mr. Chairman, I am a little bit surprised that the Auditor General can issue a report and the associate deputy minister two weeks later finds it difficult to answer some questions.

I'd like to twig your memory a little bit on this matter.

I submitted an information request asking for all documents, memos, briefings, or notes relating to results from the Lariam safety monitoring study. In response, the department provided me with a two-page review of safety data for the Lariam safety monitoring study, dated August 24, 1992. Nothing else has been received.

In that two-pager it says, “Obviously many investigators are not returning their completed case record forms.” On the next page it says, “This indicates that the safety data from the Canadian study is incomplete.” And yet the department proceeded with the licensing.

You knew in August of 1992 that the study had broken down, and it seems no action was taken. I'd like to know why.

The Vice-Chair (Mr. Ovid Jackson): I'll give you two minutes, because you're actually out of time.

I would remind you, John, that the minister's going to be here, and hopefully the discussion will be related to this. Some of these people may not be...but anyway, we'll get a response.

Ms. Marie Fortier: I guess I can only reiterate what I said earlier. I'm the acting ADM of the policy branch. I'm not suggesting that policy doesn't know what goes on elsewhere, but I don't have the detailed information to provide you today. I'd be happy to ask my colleagues in HPB to answer more fully in writing.

The Vice-Chair (Mr. Ovid Jackson): Elinor.

Ms. Elinor Caplan (Thornhill, Lib.): I don't think I was on the list, but I can always think of good questions. Since I had the opportunity for a briefing with the Health Canada officials, I thought I'd let my colleagues use the time.

The Vice-Chair (Mr. Ovid Jackson): Okay, we'll go back to Maria, then.

Ms. Elinor Caplan: There you go.

Ms. Maria Minna: No, you can go.

Ms. Elinor Caplan: I could think of a lot of questions, if you'd like me to.

The Vice-Chair (Mr. Ovid Jackson): No, no. I just wanted to be fair. It's fine if you don't have any questions.

Bev has quite a few, I'm sure.

Ms. Bev Desjarlais: No, Maria can go ahead.

The Vice-Chair (Mr. Ovid Jackson): Go ahead, Maria.

Ms. Maria Minna: We'll toss a coin.

You caught me by surprise here, but I'll go back to Abby Hoffman for a moment.

I'm wondering whether the centres of excellence or maybe some other parts of the department are looking at effects on women. For instance, I understand we do use hormones in cattle. There's a dispute now with Europe and the European economic market with respect to their not wanting to accept Canadian meat, because we do treat our cattle with hormones. Have there been any studies on that as to how...

I always have this thing that this affects women more than it does men, or affects women in a different way, and I wondered whether there was any study there. Never mind trying to export it; let's try to see what we do with it here.

Who does that studying? Is there something that maybe the centres of excellence are looking at—for instance, the kinds of hormones or substances that are used and how they might affect women in a way that's different from how they affect the rest of the population?

I'll let you answer that one, and then I'll go to the other one.

Ms. Abby Hoffman: I can't tell you specifically on that particular issue, but I can tell you that one of the mandates of the women's health bureau, which I was previously director general for... I am now in effect one step removed from it, although it still exists within my area. One of our very strong interests is in ensuring that gender considerations be taken into account in all of the work the department does.

For example, with respect to the health protection branch, which generally would be responsible for the type of work you've just identified, to go back a couple of years, that branch adopted a policy regarding the inclusion of women in clinical trials for new drugs and medical devices. That was a very important step, because prior to that time it had been quite feasible to secure approval for a new drug or new medical device that might indeed have been intended for use among women, or intended for use among the general population including women, without there actually having been appropriate trials done to test both the safety and efficacy of that item relative to women. So that's something we're very strongly encouraging.

• 1230

In order to help us make that point inside the department, the centres of excellence, although, as I said earlier, they are not themselves engaged in bench-level clinical studies but are very concerned with policy... We provided some support to the centres so that both individually and collectively they could participate in the consultation processes that the health protection branch has undertaken over the last year and that they will continue in the upcoming period with respect to their future processes, legislation, regulatory regimes, and so on. This is an issue that we're very concerned with.

To this point, there's been a good response inside the department. There is a lot more to be done, so part of what we're trying to do in that respect is to make sure that people beyond the department are actively engaged in these discussions, driving home on a recurring basis the importance of looking at specific gender impact. Obviously our concern in the women's health bureau is the specific gender impacts on women.

I want to underscore that the reception has been positive in areas. For example, in some of the work that is being done on impacts of pollution and other concerns and in some of the Great Lakes work that's being done there are specific studies that are looking at reproductive health consequences for women.

Ms. Maria Minna: Do I have time for one more question, Mr. Chairman?

The Vice-Chair (Mr. Ovid Jackson): Yes, very quickly.

Ms. Maria Minna: Thank you.

I'd like to go to the general area of policy with respect to environmental aspects. I was looking at the document that I presume was provided by yourselves this morning, which I have here—or maybe it's from the researchers. In any case, page 10-7 is about the responsibility of Health Canada, of course, to deal with hazardous materials, with testing and affairs of policy and so on.

There are two questions I have here. One has to do with whether or not you deal only with specific substances that are used in the workplace. Do you deal with general health issues like emissions from cars? Is Health Canada involved in the environmental sphere? It is in involved in a more generic, broad aspect in terms of lakes, etc.? I know it's environmental, but it affects the health because you eat the fish. I just want to understand the scope of Health Canada.

Second, when a company applies for an exemption for one of their substances, on what basis would Health Canada give an exemption, especially if it is declared to be a hazardous material? I was looking here at what it talks about. In an example of an exemption, it says here that it is valid for three years but that a person can apply for an exemption. One the reasons for giving the exemption is the possibility of disclosure, that it would reveal confidential business information.

The Vice-Chair (Mr. Ovid Jackson): We need a quick response here. We're running over our time.

Ms. Maria Minna: It's a bit complicated, but I want to understand how that works.

Ms. Marie Fortier: I'm not sure I can answer the second part of your question. There must be specific regulations that provide for what these exemptions can be. Again, this is a health protection branch responsibility. They would have to operate within the scope of the regulations. They would not generate the causes. They would all be spelled out. If the request is consistent, it could be granted; otherwise it couldn't. I can certainly ask them to provide you with the nature of these exemptions.

Ms. Maria Minna: I'd appreciate that. Thank you.

Ms. Marie Fortier: With respect to environmental health, it is clearly the responsibility of the Health Department with respect to health impacts and making the assessment of health impacts, with Environment Canada being responsible for the broader standards and their promulgation and implementation.

Ms. Maria Minna: Is this where...

[Editor's Note: Inaudible]

...kick in?

Ms. Marie Fortier: Yes, it's a joint responsibility. Health Canada says yes, there's a health impact and advises Environment Canada accordingly, or Environment Canada asks if there is a health impact and the appropriate studies are done or commissioned in order to be able to answer that question. There's overlap—but necessary overlap—between the two departments.

• 1235

The Vice-Chair (Mr. Ovid Jackson): Bev.

Ms. Bev Desjarlais: In regard to the development of the national home care program which, it is acknowledged, doesn't necessarily fall under the scope of the Canada Health Act, there is a nationwide indication that there's a desire to have a national home care program. Certainly, in looking through the estimates and the plans in the department's near future, it's not obvious as to when the department plans on realizing a national home care strategy. Is there something in the works? Is there a timeframe that has been put in place?

Ms. Marie Fortier: No. No decision has been made on whether to move in that direction with a national program, as you frame it, or when that might happen. What's clear is that there is a lot of concern throughout the country about variability in and access to home care. Not everybody finds it equally easy, and there are restrictions and limits on how long people can remain in home care programs.

Everybody is working toward improving that, but the first step—and it was quite clearly the very strong message from provincial governments—was to stabilize the health care system by putting in additional resources for the next few years. That was done in the last budget and that provides a stronger foundation on which to build enhancements in health services, which inevitably will be needed as the population ages. In fact, all provinces, in the last year or two, have expanded resources in home care and continuing care.

The issue is actually more than just home care; it's the whole range of services that people need as they become disabled because of aging or for other reasons. That includes the mix of assisted housing, institutional care, home care, etc., and how easy it is to move back and forth between those levels of care as you need them. We're working with the provinces very intensely on figuring out the elements of the continuum. As time goes by, if the federal government chooses to invest more directly, obviously we'll need to consult fairly intensely with provinces.

Ms. Bev Desjarlais: You may or may not be aware of the extramural health care system as utilized in New Brunswick.

Ms. Marie Fortier: Yes.

Ms. Bev Desjarlais: I've had the opportunity to actually see exactly how it works out. To me it seems like a absolutely excellent model, weighing costs between hospitalization or at-home care; it is very inclusive of all sections of home care, from occupational therapy to physiotherapy and respiratory therapy.

Having seen such a model in the works, I have to wonder why there has to be such an overwhelming push for us to try to research the whole issue again when there's a model that has been working for, I believe, a number of years now in New Brunswick and seems to be addressing the exact area that we're talking about.

Ms. Marie Fortier: It's an excellent model. It addresses a lot of the needs, but it doesn't address all the needs, even in New Brunswick. As far as we can tell, there are gaps with respect to longer-term care and home support. That's a challenge everywhere.

The fact is, that model—and it's not necessarily our role to impose a single, unique model across the country—might not work so well in provinces with a larger territory and more isolated communities. But it's certainly one that we're familiar with, and we are working with New Brunswick to learn from it and to learn about the gaps and the problems they themselves have identified.

Ms. Bev Desjarlais: Okay. If I just follow up on Maria's question about when Health Canada kicks in, would you be involved at all in the consequences of the Plastimet fire in Hamilton? There were certainly indications that everything that sort of flowed into the air wasn't exactly all wonderful for people in the area. Did health services ever get called in on that issue?

Ms. Marie Fortier: I don't know. Quite honestly, I can't answer that. I could find out.

• 1240

There could have been a role. The first line of intervention would have been local. The local public health authorities would have stepped in first. They might have called on the province to help them. There is an excellent link among local, provincial, and health protection branch public health authorities. They usually work together very closely if tools are needed, if advice is needed, if instruments are needed. These things do go on all the time. People will go and help out. It may or may not be by reason of a formal legislative mandate; it may be because of a collaborative arrangement.

Ms. Bev Desjarlais: Thank you.

The Vice-Chair (Mr. Ovid Jackson): Mr. Cummins.

Mr. John Cummins: Thank you, Mr. Chairman.

I'd like to ask a few more questions on this issue of the antimalarial drug, mefloquine. What I want to do first is bring to the attention of the committee the health protection branch's troubling lack of awareness of a mefloquine-related suicide by a Canadian soldier on December 25, 1994. The Canadian Forces conducted a summary investigation and concluded that mefloquine was a contributing factor in the suicide, yet the health protection branch's only knowledge of this highly publicized suicide triggered by long-term mefloquine use was an unconfirmed newspaper report, according to documents I received from the Health Protection Branch. I'd like to ask if it is standard procedure for the health protection branch to deal on just unconfirmed newspaper reports.

The Vice-Chair (Mr. Ovid Jackson): We'll probably get similar answers.

Mrs. Caplan, can you answer the question?

Ms. Elinor Caplan: Mr. Chairman, if I may—and I think it is fair—the last group that we had from Health Canada included the health protection branch people. Mr. Cummins was here, asked a first question, and then left. We actually pursued this issue and discussed it with the health protection branch people at that time. These folks are not from the health protection branch.

Ms. Maria Minna: We could bring them back.

Ms. Elinor Caplan: If you want to bring back the health protection branch people to further their questioning or perhaps read the committee Hansard from the last meeting, you might have your questions answered. It's not fair to go down a line of questioning with the wrong branch.

The Vice-Chair (Mr. Ovid Jackson): Okay. Just to make sure we keep some order here, comments should be through the chair; he has the right to ask the questions.

Perhaps, John, since you've asked this question before and since the minister will be here, maybe we could ask to have some of those health protection branch people come back at that time. Would that be fair game?

Mr. John Cummins: What my purpose was, and I appreciate the comments of the member opposite... I understand that we do have the associate deputy minister here, which crosses all lines. That's my understanding; I may be wrong. I wanted to get some of these issues on the record. I think they're important matters. I believe there were some serious problems in the health protection branch on this particular issue. I'm not sure whether this is the pattern for the health protection branch or not, and the issue, of course—

Ms. Elinor Caplan: Mr. Chair—

Mr. John Cummins: —was confirmed by the Auditor General. I wanted to bring that issue out. I think the public deserves an answer on that.

Ms. Elinor Caplan: Yes. In fact, perhaps I could repeat what was said at the last meeting, just to help the member at this time. It's my understanding that the timeline for this was 1992-93, at the time of, actually, the previous government. The drug mefloquine, better known as an antimalarial drug, at that time had not been approved for use in Canada, although it had been approved for use in other countries. As they said at the last meeting, it was just about ready for approval. It was subsequently approved, I believe, in late 1993 or in early 1994. That drug is now fully available in Canada, having completed the trials.

There are two ways of accessing drugs for emergency use. In this case, Canadian troops were going to Somalia. They wanted to protect those troops from malaria. There were two ways of requesting the use of that drug from Health Canada. One was under a special authorization and the second was as part of a clinical trial. It was deemed appropriate that it be done as part of a clinical trial, and there was confidence at the time because the drug was just about to be approved. They felt that was the appropriate way of proceeding.

The comments from the Auditor General have been taken very seriously by Health Canada in monitoring those types of requests that might come in time of urgent need. No one is suggesting that what happened in the past was necessarily perfect. That's why we have the Auditor General, who looks at these things and makes recommendations and so forth.

• 1245

But for people listening, it is important to know that mefloquine is approved in Canada today. It was approved shortly after that period of 1992-93, and it was at the request of the defence department that the drug be made available to protect Canadian troops who were going over to a part of the world where malaria was prevalent.

Those were the facts that were presented for the committee at the last meeting, and if the member wants to pursue his line of questioning, I'm sure that the appropriate branch of Health Canada would be very happy to restate and comment, as I've just done.

That's what was said at the last meeting.

The Vice-Chair (Mr. Ovid Jackson): We're going a little bit over our time, but do you want to—

Mr. John Cummins: Can I respond to the member's intervention, please?

The Vice-Chair (Mr. Ovid Jackson): Yes.

Mr. John Cummins: Part of the job of the health protection branch is the ongoing monitoring of some of these drugs, yet, in 1997, we requested a list of adverse reaction reports and got one, and there were only 25 adverse reaction reports listed, including the one that I just mentioned, about the suicide in Rwanda. That 1997 list fails to include hundreds of often-disabling adverse reactions experienced by Canadian soldiers in Africa between 1992 and 1995. The force could have provided health protection branch with literally hundreds of reports, but they're not here. They're not available. Health protection branch doesn't seem to have them.

With regard to the deployment to Somalia, in fact, studies done by the Department of National Defence indicated that there was a problem with that drug. Prior to the deployment of the troops in Somalia, we had people in Somalia who had experienced difficulties, and I'd be pleased to make that documentation available to the member opposite. There was ample warning that the drug could cause problems. You can even go back to the World Health Organization, which identified problems in Thailand and recommended that the drug be used with caution with soldiers, given the critical situation.

This is a serious issue and I would have thought that somehow or other some answers to this would be forthcoming.

Ms. Elinor Caplan: Mr. Chairman—

The Vice-Chair (Mr. Ovid Jackson): I'm sorry—

Ms. Elinor Caplan: But the point is this—

The Vice-Chair (Mr. Ovid Jackson): —but we're out of time for this question. I'm sorry, Ms. Caplan.

Ms. Elinor Caplan: When the health protection branch people are here, I'm sure they'd be happy to answer the member's questions specifically.

The Vice-Chair (Mr. Ovid Jackson): Okay.

Ms. Elinor Caplan: They were here. He wasn't.

The Vice-Chair (Mr. Ovid Jackson): Yes, but we're out of time, and we're not supposed to mention whether members were here or not. The point is, he has asked his question and, hopefully, when the minister comes here, if there's any further information it will be forthcoming.

I'll move now to Madam Minna.

Ms. Maria Minna: Mine is just a minor question. I go back to this document I have. Mr. Chairman, I'm not sure whether this was provided to me by research or by our witnesses. By the witnesses... Okay. I just want to go to pages 10-4 and 10-5. There are two lines. One line says that “grants towards the Canadian strategy on HIV/AIDS” are $8,010,000, and on the next page, still under transfer payments, it says that the “contribution towards the Canadian strategy on HIV/AIDS” is $20 million. Which one is right?

Ms. Marie Fortier: They're probably both right, but they probably describe two subsets of something.

I'm sorry, Mr. Chairman, but I don't know who tabled that document. None of us did, so I'm not sure what you're referring to.

Ms. Maria Minna: I was handed it this morning when I arrived. I assumed that you had brought it with you.

Ms. Marie Fortier: No, we didn't.

Ms. Maria Minna: I have the one on aboriginal health and this one.

Ms. Marie Fortier: It may be that one refers to an annual number and the other one to an overall number.

The Vice-Chair (Mr. Ovid Jackson): Okay. That was supplied by the clerk, not by our visitors.

Ms. Maria Minna: Fine. I apologize for that, then.

Mr. Chairman, maybe I can...

Ms. Marie Fortier: Perhaps if we could look at it, we might be able to answer your question. It's just that we... Bob, I'm sure, would understand the numbers if we could have a look at it.

Ms. Maria Minna: We're probably dealing with subsets.

The Vice-Chair (Mr. Ovid Jackson): Just to make sure that we expedite this thing, as I understand it, we will discuss the estimates—

Ms. Maria Minna: Mr. Chair, I can—

The Vice-Chair (Mr. Ovid Jackson): —and perhaps, Madam Minna, at that time you will get your answer to the question. In the meantime, I have three questions I'd like to ask.

Mr. Cummins.

• 1250

Mr. John Cummins: On a point of order, Mr. Chairman, I'd just like to indicate as well that I did send a letter to the committee as a result of that meeting last week. I think the issue I've raised here is one that the committee should probably address. They may well want to bring people from the health protection branch forward to answer questions, because I think this certainly deserves it. I just want to make that comment.

Unfortunately, I do have to run. I'm already late for a meeting, but I just wanted to make that observation.

The Vice-Chair (Mr. Ovid Jackson): Thank you.

Mr. John Cummins: Thank you.

The Vice-Chair (Mr. Ovid Jackson): I have a number of questions. I want to give myself just as much time as everybody else had before I go back to Bev.

The first one has to do with the home care branch. Is it a branch unto its own? What kind of staffing and resources do you have?

Also, a few years ago, we had a major discussion with regard to a national pharmacare program and then it sort of disappeared. Is there any further information on that?

Ms. Marie Fortier: Thank you, Mr. Chairman.

With respect to home care, it's called a branch but that's merely because it was set up as a separate entity. Probably in due course it will be integrated into the department. At the time it was set up last year—and I was personally asked to set it up—it was easier to not try to figure out where it belonged in the organization but to just attach it to the deputy minister directly. In reality, it is a very small group of people. There are about 18 now. We're actually just in a transition process. Some people have left and we're looking at new arrangements for the foreseeable future.

With respect to pharmacare, that work has actually continued and has always had a home in the policy branch. Pharmaceutical issues had been under review for some years. Over time in the provinces, the territories, and the federal government, there was some interest in looking at a number of aspects of drug costs, drug utilization, and related matters. Frank might be able to say a few words about that because he's the director responsible for that work. That work has continued. The federal government remains interested in improving access to drugs for Canadians and certainly we've been working with provinces on that, but there is also concern about escalating costs.

Drug costs have continued to grow much faster than any other aspect of health expenditures. There are a number of reasons for that. Certainly increased utilization is one, but the increased prices of individual drugs is another factor. Work is ongoing to find different avenues to help manage that through clinical practice guidelines, through better sharing of information, and through collaborative work among provinces on the decision-making process with respect to whether a drug should be covered or not. Very expensive new drugs come on to the market and it's not always clear that they offer a lot of improvement over older drugs that are available at a lower cost.

These are tough decisions for provincial governments, all of whom have drug plans that provide fairly extensive coverage, and, of course, for our medical services branch as well when these drugs come on to the market. The federal government faces that same issue in Health Canada, as do other programs for veterans and other people who are covered by the federal government.

Maybe Frank can add a little about the work that's going on in the area of pharmaceutical issues.

Mr. Frank Fedyk (Director, Health System and Policy Division, Policy and Consultation Branch, Department of Health): Mr. Chairman, we have the federal-provincial committee, the pharmaceutical issues committee, which members of the provinces, territories, and the federal government sit on. We are, as Marie elaborated, looking at the full spectrum of pharmaceutical issues—access—and we are using one of the health transition fund's national projects to examine that and to provide the actual evidence and information on what type of coverage Canadians have, on who has no coverage, and on the quality of the existing coverage through available public or private plans—thereby knowing exactly who in fact may be at risk because of co-paid deductibles or premiums.

• 1255

Other issues deal with the utilization, as Marie said, in terms of clinical practice guidelines. We held a workshop with the Canadian Medical Association in which general family practitioners as well as pharmacists and drug manufacturers participated. They are interested in collaborating to ensure that the right drug gets prescribed at the right time for the right person.

That is just some of the very specific nature of the projects we're working on at this time.

The Vice-Chair (Mr. Ovid Jackson): How are you making out with the registry to prevent double-dipping, so to speak, to prevent shopping around for different physicians?

Mr. Frank Fedyk: Most provinces have on-line judication, just like the medical services branch does; it comes up if there are in fact multiple prescriptions being filled within a very short time.

Ms. Elinor Caplan: I have a follow-up question on pharmacare.

The Vice-Chair (Mr. Ovid Jackson): I'll come around to you. I'll go to Bev first.

Ms. Bev Desjarlais: Let her go ahead.

The Vice-Chair (Mr. Ovid Jackson): All right.

Ms. Elinor Caplan: I have a follow-up question on the delivery models. As you said, all provinces have drug plans. I'm wondering whether Health Canada is doing any examination of those models on the basis of their outcomes.

The goal of all drug plans should be, in my view, and in, I think, the view of most optimal therapy, that people get the drugs they need to improve their health status. We know that the result of many of those drug plans has actually been to make people sick, because the drug plan is set up as a benefits plan as opposed to a plan that actually monitors the results in any way. I'm wondering what work Health Canada is doing in designing models that would give greater results in the area of access to medically necessary drugs.

Mr. Frank Fedyk: There is an HTF project, one of the national projects, that's being funded. That's just in the initial stages. It is looking at the various approaches, not just at the Canadian models but at the European models. That project was just announced in February so it's just starting. It will be looking at it not, as you said, strictly from a benefits perspective but in terms of the outcomes, the impact in terms of drug therapy dealing with the health needs of the individuals. When that study is complete in about a year, there will be a paper we can all use to benefit from and to make corrections and adjustments to the various plans across the country.

The Vice-Chair (Mr. Ovid Jackson): You can have some more time.

Ms. Elinor Caplan: May I?

I think that's really important, because when we look at access to medical services and to drugs in particular, we know that often drugs are being used to replace other kinds of interventions. If the incentive in a program is just simply to dispense the drugs and not give the result of improved health status for the individual, it's a real problem. I'm happy to hear that there is an international component to it. I guess the other part of that is whether the provinces are participating and how that's being set up.

Mr. Frank Fedyk: Yes.

Ms. Elinor Caplan: You had a conference on pharmacare.

Mr. Frank Fedyk: Yes.

Ms. Elinor Caplan: Were those kinds of models and concerns raised at that conference?

Mr. Frank Fedyk: Yes, very much so. All HTF projects involve both FPT oversight in terms of determining which get funded... In particular, that one has also set up a steering committee that involves federal and provincial representation.

Ms. Elinor Caplan: That will be done in about a year?

Mr. Frank Fedyk: In about a year.

Ms. Marie Fortier: I think the other part of this that's very important is that drug benefits or the provision of a drug are not isolated events; it's very important to look at this as part of an integrated system of care, which is one of the perspectives that the health transition fund has had constantly in looking at drug issues as part of the totality of care that a person receives. Obviously there needs to be interaction between physicians, pharmacists, and other caregivers with respect to monitoring the impact of drug therapy, identifying inappropriate reactions, etc.

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Ms. Elinor Caplan: The point I'd make on that, which is an important part of the idea of continuum, is that when someone is in a hospital they're given the drugs they need but they're given them in a fairly controlled environment, where everything's marked on the charts and the outcomes are monitored. When you leave the hospital and you're out in the community, the chance of getting those drugs depends upon the province you're in and so on and so forth, but it's given in a completely “unmonitored”—I guess that's the word I would use—environment.

Ms. Marie Fortier: Yes.

Ms. Elinor Caplan: Except perhaps if you have a really good family doctor who's trying to keep track of it all... But isn't that a big part of the problem?

Mr. Frank Fedyk: Very much so. Part of the CPG studies that are—

Ms. Elinor Caplan: CPG...

Mr. Frank Fedyk: Clinical practice guidelines. Part of those studies—which are also being supported through HTF—is ensuring that there is appropriate prescribing so that only the right drugs are being prescribed. Inappropriate prescribing is being addressed, and there are also studies dealing with the impact of those prescriptions in terms of trying to ensure that the consumer is getting the right information.

One of the other HTF projects is to develop a drug guide for us as consumers of products so that we are ensured we're asking the right questions in terms of the associated risks or benefits and in terms of the potential side effects as well, so that we are able to deal with adverse reactions. For example, as you said, in a hospital there's very close monitoring, and if you're in a community you don't really know.

The Vice-Chair (Mr. Ovid Jackson): Bev, they're out of time, but Maria said she had a question. Would you give her a chance in this general trend?

Ms. Bev Desjarlais: Sure.

The Vice-Chair (Mr. Ovid Jackson): All right.

Ms. Maria Minna: Thank you. Just to follow up on the notion of drugs, given the facts that there are a lot of new ways of treating illnesses and that people are being let out of hospital a lot sooner—sometimes two or three days after surgery—but are continuing to take the drugs they normally would have received in the hospital—and without those drugs they may not heal as well and a lot of people can't afford them—is Health Canada looking at that issue as a possible access issue for health care? There are the five principles... In a way, what was once available in a hospital is now not available outside, and if you can't afford the drug you tend to get off it earlier. That obviously means that you're not getting the same kind of health care. That's an issue of accessibility, I would think. Are you looking at that at all?

Ms. Marie Fortier: My colleague might want to expand on my answer. At the moment, we're primarily looking at it from the point of view of home and community care; it's drugs but also devices and supplies that you receive free in the hospital but don't have access to when you come home. Some of these supplies or devices can be quite expensive or completely out of reach for individuals to purchase. Some of them are provided by provincial governments—but not all. It is an issue. Whenever you speak about home care to any group, people raise that as a big barrier that has to be dealt with as part of the definition of what ought to be the basket of services, if you will, that comes under the heading of home care.

Colleagues, would you like to add anything to this?

Ms. Maria Minna: That's fine. I understand that it's home care. I was also looking at it from the point of view of accessibility to health in terms of living up to the five principles of the health care system, because if you can't heal to the end you're not getting access.

Ms. Marie Fortier: If you take the Canada Health Act provisions with respect to accessibility, you have to play them out in the context of the definition of comprehensive services. Comprehensive services include hospital and medical services and the services of other professionals that are recognized by provinces as part of comprehensive services. Those services must be accessible.

That's not to say that the Canada Health Act in itself limits anything; it sure doesn't. Our view right now is that we have to get a better handle on the way in which these gaps play out in the country and on how much more money might be needed to fill that. There's no question that the new resources made available in this last budget will go, in some provinces, toward filling those gaps.

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As time goes on, we'll reach probably a greater level of consensus about all of that, and provinces will be moving in a similar direction. They have recognized home care and continuing care as a common priority. Ministers of health, a little over a year ago, chose that as one of their five or six key priorities. At their next meeting in September when we report to them on progress to date, we hope that priority will be reinforced, and we hope that we will continue to work jointly on moving home care more into mainstream health services.

Ms. Elinor Caplan: In many home care programs across the country, to buy drugs—

The Vice-Chair (Mr. Ovid Jackson): I'm sorry. We're out of time. We'll have to come back to this. We'll go to Bev. I have to be fair.

Ms. Bev Desjarlais: These are good questions and it's good to see what the follow-through is, because there's no question from my perspective—and I mentioned knowing what happens within the extramural system in New Brunswick—that what ends up happening in a good many situations where it can't follow through is that the patient is kept in hospital because the physician knows there is no way they're going to be able to afford it. The cost balance isn't there.

Speaking along the lines of drugs and cost, there would be those who suggest that the costs are quite high because of policy we have for dealing with drug patents, that type of situation, which certainly has allowed drug companies to maintain some high rates for their medications.

The international pharmaceutical industry is now pursuing direct-to-customer marketing of drugs. What's Health Canada doing in that area?

Ms. Marie Fortier: We certainly don't encourage direct consumer advertising. It's not permitted under current legislation in Canada. As Frank alluded to earlier, there is a need for consumer information—not necessarily provided by those who sell the product.

Last week, I believe, Denis Gauthier spoke about one of the things we are doing. He may not have gone into this particular aspect of the work he's doing. We are making consumer information available to the public through a combination of Internet and 1-800 access so that people can find the appropriate source of information about a variety of things like a drug or a device or a product, but also about the way to manage a condition they might have a concern about. Again, drugs usually are part of a broader spectrum of practices that people need to be aware of when they are trying to cope with an illness or even with a health issue.

Ms. Bev Desjarlais: Isn't the key factor in this whole process the physician?

Ms. Marie Fortier: Yes, it is.

Ms. Bev Desjarlais: If that physician takes on the treatment of that patient, isn't it their responsibility to ensure that all that happens if they're putting the patient on those medications? Why are we searching for answers everywhere with regard to getting this information to the patient when you have a physician prescribing and that's his responsibility as part of treatment of the patient? That's my understanding of a physician's responsibility in this whole process: there is a responsibility to ensure follow-through treatment, to ensure that the patients know why they're taking the medication and know the consequences of the medication.

I know that pharmacists follow through with that in a good many cases. Now, I believe, some provinces have it in place such that all the contraindications—everything related to the drug—has to be given out at the time. A good many pharmacists will go through all of that with you, the patient, as well, but ultimately my understanding of the physician's responsibility is that they are to do that as part of the course of treatment.

Ms. Marie Fortier: You're absolutely right about that, and I don't think anything we're doing is intended to take away from that. On the contrary, it's intended to reinforce the role of physicians and pharmacists. Physicians actually believe this too: people have the primary interest of looking after their own health and they make their own decisions. It may not just be about drugs; it may be about the combination of drugs and eating habits and physical activity level that is suitable for a given condition.

The kind of information we would make available would not in any way try to get around doctors. In fact, in many cases, people are advised to go back and seek their doctor's advice before they change a practice, but there are so many other things that people wish to know, and we really feel that we should respond to that need.

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A lot of the advice that Health Canada has supported in health promotion activities over the years, for improving physical activity and improving good eating habits... It's fine to put ads on television, as we did when we had more money to do that, but it really is when the person is interested in finding an answer to their own concerns that they're most apt to integrate the information and really make the choice of a change in their life—rather than just seeing an ad here and there. Responding to individual needs for information is an adjunct to all of that, and there's no question that a lot of that work is in fact done in collaboration with medical associations and pharmacists to make sure. The last thing we want to do is to put out information that is incorrect or is contrary to good medical or pharmaceutical practice.

Ms. Bev Desjarlais: Thank you.

The Vice-Chair (Mr. Ovid Jackson): Bev, I kind of threw away the clock there. You're fine...

Madam Caplan.

Ms. Elinor Caplan: I thought I would answer the question on Plastimet. There is an answer, and that is, at the time of the fire Health Canada officials offered assistance to both the province and the local officials on an as needed basis. The offer was not required. Assistance was not required. The province and the local municipality felt they were able to handle it without any assistance—but the offer was made from Health Canada. I just thought you'd want to know that.

Ms. Bev Desjarlais: May I follow up on that response?

The Vice-Chair (Mr. Ovid Jackson): Sure.

Ms. Bev Desjarlais: My understanding of the Plastimet fire is that when the winds blow they don't stop at the edge of Hamilton or Stoney Creek or wherever; the winds carry whatever is happening a little bit farther. If that offer was declined, how can Canadians ensure that their health has been protected? Is there some way for Health Canada to move and say they're going to do it anyway because they're not convinced that all is hunky-dory?

Ms. Elinor Caplan: I think Marie's answer was the right one. She talked about a collaborative approach by the provinces and the federal government in those areas of concern about public health and safety: to work very closely together and share the same goals. If there's a concern, Health Canada would express that. Similarly, I know that for the provinces, which have both ministries of health and ministries of the environment and so on and are supported by local public health networks, in this collaborative model we're closer together.

Health Canada has a broad surveillance network whereby they gather information. I think what's really important is the collaborative model, as opposed to anyone seeing Health Canada as marching in because of their mandate overriding provincial interests. That's not the way the country works; it is a collaborative model. But certainly, if Health Canada officials have concerns, they are very comfortable—and it is appropriate—in raising those with provincial authorities, and they work those out together.

In the particular case you asked about, it's my understanding that when it happened Health Canada officials said, look, if you need us we're there and we'll do whatever you request. The province said thanks very much; they appreciated the offer of assistance but it was not required.

The Vice-Chair (Mr. Ovid Jackson): Thanks for that exchange. I have one question of my own, which has to do with the health transition fund. It's almost finished now, and you should be starting to get the results of your models and projects. Can you share any information with us? What's the status?

Ms. Marie Fortier: None are actually completely finished, but a number of initiatives are being planned to do just that: to bring together the people who led these individual projects so they can share their experiences. They all have a requirement to conduct an evaluation and to disseminate that evaluation, either by publishing articles or by reporting publicly on the projects in one way or another. They will all do that.

In addition to that, we're going to organize some evaluations of the projects as groups of projects. It's one thing for each to evaluate how successful they were, but it really isn't possible for them, individually, to look at the lessons learned across a series of projects on primary care reform, let's say, or in other areas like home care or drug issues. That's something we're organizing with the project proponents and the provinces.

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It will take another two years before we get all that drawn together and before we can say, for instance, that what we've learned on primary care is that the following five things can be done or cannot be done or don't work. Really, it may sound strange, but it takes that long for the whole cycle to play through. Some of the projects actually were just initiated late in 1998 and a few are yet to be announced. We still have a lot of time ahead of us before we can reap the benefits of what has been initiated through that.

The Vice-Chair (Mr. Ovid Jackson): Do we have any further questions?

Bev.

Ms. Bev Desjarlais: I have a quick question. Is there maybe a suggestion that patients have the right to know? I'm not suggesting a patients' bill of rights, but I'm just thinking that people have expected forever that everything the nurse and the physician do is in their best interests, and they accept what they're told as gospel—for the most part. It's changing a bit. Let's say it's posted in physicians' offices, hospitals, and health care clinics that patients have a right to know this and this, so ask your physician, or ask the nurse. Sometimes, I think, patients don't think they should necessarily ask those questions.

Ms. Marie Fortier: Good point. I think some medical associations actually have little brochures that are handed out, are put out in doctors' offices, and encourage people to ask some questions. I think it's a gradually occurring shift in Canadian society's values and expectations.

If you look at age groups, older people are less inclined to question their doctors. Some younger people are very inclined to question and will take no advice without going through a fairly rigorous questioning. I think doctors and patients and pharmacists and patients need help and tools to make that interaction constructive for everyone.

There are people who now know more than their doctors about their own condition because they spend the time researching it on the Internet—and sometimes find information that is more or less reliable. That is one reason, by the way, that we wanted to become involved in ensuring that when people come through the Health Canada site and ask for information they can at least be assured that some sources are judged by us as being reliable and people have access... It's not that we'll vouch for everything, but at least we can tell them that this site is a reliable source, but that one we don't know about.

There have been some individual movements of groups like the HIV/AIDS community, like the breast cancer community, which have taken hold of all of these issue themselves and have become a resource for each other. Sometimes it has caused some uneasy relationships with professional caregivers, but I think the result of it all is to the benefit of everyone, including the health care provider.

Ms. Elinor Caplan: The other is just to reinforce the Canadian health network, and I think that's what Marie was referring to. That's a project that is really in its beginning phases and that I hope will respond to certainly our generation's desire to know more and to have access to accurate information.

But part of the problem, I think, is also that over the years people haven't always felt comfortable in asking the questions. Providing this information hopefully will encourage that dialogue and the empowerment of individuals to recognize that they're an important part of their own health team and have a responsibility to have the information and ask the questions so that they can take the actions that are in their best interests.

The Vice-Chair (Mr. Ovid Jackson): Bev, are you all questioned out?

Mr. Lafleur.

Mr. Robert Lafleur: Mr. Chairman, if I could just close the loop on the questions asked by Maria Minna. The document she was referring to is a copy of a portion of the main estimates. The numbers she was interested in are part of the same strategy on HIV/AIDS. They're both transfers; in one case it is grants and in the other case it is contributions. I gave her the information.

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Ms. Maria Minna: Thank you.

The Vice-Chair (Mr. Ovid Jackson): Thank you very much for being here.

This meeting is adjourned.