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THE REFORM PARTY DISSENTING OPINION ON THE STUDY OF THE NATIONAL AIDS STRATEGY

Sharon Hayes, M.P., Port Moody-Coquitlam

INTRODUCTION

The Sub-Committee on HIV/AIDS was established in November 1994. The mandate:

A review of the role played by government in the fight against HIV/Aids was the first phase of the study. The Sub-Committee heard testimony from organizations, professionals and Health Department officials to specifically review programs of phase II of the National AIDS Strategy "with the purpose of identifying weaknesses and strengthening response through the National AIDS Strategy".

The Report on the Study of The National AIDS Strategy covers the results from hearings from 14 Dec 1994 to 31 May 1995. Close scrutiny of the report indicates serious flaws and points of contention about its conclusions. This dissenting opinion reviews the validity of the process, comments on specific weakness of components of the strategy and outlines the lack of prioritization, accountability and evaluation within several aspects of the strategy.

Spending Priorities: Within Health Canada

The epidemiology of AIDS in Canada, the U.S. and the world is given some attention in the report. The level of federal activity and funding, however, must be considered in comparative terms with other major diseases that are prevalent throughout our population. Increasingly limited federal financial resources demand that all government program commitments, whether in departmental resources or funding, be seen in light of domestic funding priorities. Health Canada is no exception. Any comparison to or position in relation to other health strategies within this department is noticeably absent from all discussion in this report .

In fact, the Sub-committee's focus does deal only with the issue of federal funding and expenditures in combating HIV/AIDS. As outlined in the report, Health Canada has allocated some $40.7 million for the budget for Phase II of the Strategy for 1995-96. Upon completion of Phase II in 1998, the Strategy will have been allocated $203.5 million (1993-1998 inclusive).(1)

(1) Summary of Testimony. Prepared for the House of Commons Sub-Committee on HIV/AIDS. O. Madore and W. Murray, Research Branch Library of Parliament, p. 9.

The significance and suffering that this disease has inflicted in our society is acknowledged. Like other health concerns there are definite commitments needed for prevention, care and research. However, it is also true that many other than AIDS, such as breast, prostate and cervical cancers or cardiovascular and liver disease, are potentially preventable, and severely threaten the health of our population.

A comparative analysis indicates that federal spending priorities do not in fact reflect the incidence of disease. The Minister acknowledged during her testimony before the Sub-Committee that fiscal and budget realities impose certain constraints on choices that could be made in allocating federal funds. The choices that have been made clearly show not only existing priorities of government spending, but the price that is exacted on other health initiatives on account of these priorities.

Expenditures on Selected Programs ($ Millions)(2)

1986-87

1993-94

1994-95

AIDS Strategy

Program

0.0

9.4

15.1

Community Action

1.4

16.3

19.6

Research

0.0

9.3

8.7

Total

1.4

35.0

43.4

Breast Cancer

Program

0.0

0.9

1.1

Community Support

0.0

0.5

0.5

Research

1.0

1.4

2.5

Total

1.0

2.5

4.0

Cardiovascular Disease

Program

0.0

0.0

0.0

Community Support

0.0

0.4

0.6

Research

0.7

3.4

3.2

Total

0.7

3.8

3.8

(2) Planning, Analysis & Reporting Division, DPFA, CSB EGR14/PARLREQ November 2, 1995.

In relation to this data, it is interesting to note as well that the total incidence of HIV in Canada as of the end of December 1994 was 10,689 cases with 7,471 deaths. That should be compared with the estimated incidence of 17,700 cases of breast cancer diagnosed in 1995 alone with 5,400 deaths.(3)

(3) Canadian Cancer Statistics 1995, National Cancer Institute of Canada, pp. 18-20.

The report also reflects the predictable and outmoded mentality of year-end government spending. In its seventh recommendation, the Sub-committee advised Health Canada that it should spend the "full amount of budgeted funds during each fiscal year" allocated to the National AIDS Strategy (p. 17). In effect, the Sub-Committee has recommended that the amount budgeted should be spent irrespective of whether such an expenditure had a specific purpose and was justifiable.

Such an approach only opens the process to dubious politicization of the budgeting and funding process. In other words, this year-end spending mentality does nothing for the prudent, judicious and effective expenditure of public funds to deal with this disease. In fact, the Sub-committee has adopted a position that is opposite to that of the Minister. In her testimony, the Minister emphasized the need for prudent and effective spending to achieve the Strategy's goals rather than spending for the sake of spending.(4)

(4) Testimony by Diane Marleau, Minister of Health. Minutes of Evidence and Proceedings 1:10


Spending Priorities: Within the National AIDS Strategy

The following table reflects the budget allocations within the National AIDS Strategy:

Component

Average Annual Allocation

Actual Budget 1993-1994

Allocation for 1994-1995

Allocation for 1995-1996

Community Action

9.8

10.4

9.8

9.8

Education and Prevention

6.2

5.3

6.3

6.3

Research and Epidemiology

17.8

15.6

18.7

16.7

Care, Treatment and Support

5.4

3.3

8.6

6.4

Coordination and Collaboration

1.5

1.0

1.7

1.5

TOTAL

40.7

 35.6

 45.0

 40.7

There are several rather disturbing trends apparent in the table and the accompanying discussion in the report.

It should be noted that 1995 allocations directly correspond to the average of the previous two years expenditures. Neither of these years, or in fact any other previous pattern of expense has been evaluated as to effectiveness, and yet an average of these two record-high years has been accepted by the Sub-Committee on the advise of stakeholders and grant recipients.

Another observation is that actual care treatment and support of AIDS victims falls far down the ladder of priority. It is in fact approximately 1/6 of the overall budget. Arguments for funding that relate to the high costs of drugs and care for an AIDS sufferer (approximately $100,000 per patient and much of which lies outside traditional healthcare) are obviously well down the priority list of the AIDS Strategy, well after funding for awareness and "behavioral change" within the education and community programs. The rather vague and unaccountable program expenditures going towards community action ($9.8 million) and education and prevention ($6.3 million) are given funding approximately equal to that of research ($16.7 million).

PROGRAM EVALUATION AND CO-ORDINATION

There is some debate as to the efficacy of strategies of this type. This is reflected in the testimony of several witnesses as well as research reports from Switzerland, a country that has the highest reported AIDS rate in Europe . A mid-term review was called for, but will not be available until later this year.

In fact the results of the pending mid-term review should be mandatory for both the design and funding decisions that must be made by the committee in its recommendations. It is entirely inappropriate to be making long term commitments with no basis from experience.

The Report's eighth recommendation advises that "the Minister of Health ensure that funds earmarked for the National AIDS Strategy are properly managed" (p. 17). However, this recommendation has no mechanism to ensure that goal.

The Sub-Committee recommends in its twelfth recommendation that Health Canada should "re-address the issue of core vs. project funding" (p. 24). Yet, as the Sub-Committee's report has indicated, there are already problems associated with the misuse and mismanagement of funds that the mid-term review is currently examining. A shift to entrenched, and often unaccountable operational funding, will not resolve those problems, and may in fact compound the dilemma of obtaining meaningful evaluations in the future.

The Sub-Committee's report has also failed to consider the cost to Health Canada and the government for implementing its recommendations. The twenty-three recommendations are open-ended.

GOVERNMENT ACTIVISM, CHILDREN AND FAMILIES

The report took into account epidemiological data from around the world but failed to reflect on related research as to the effects of similar "integrated" approaches in other places. A Swiss Study of a program very similar to the Integrated Aids Strategy has some disturbing implications. This multifaceted intervention program involved a five year public campaign aimed at increasing condom use in Switzerland and focusing on "safer sex". The data indicated that in three years into the program "girls aged 16 and younger tended to exhibit a higher rate of sexual activity"(italics added). "From 1987 to 1990 the percentage of 16 year olds who had had sex increased from 36 to 57 percent in females and from 58 to 63 percent in males".(5)
(5) "Dealing With AIDS: Quo Vadis?". Stephen and Shelagh Genuis. Journal of the Society of Obstetricians and Gynaecologists of Canada March 1995. p. 220.

Our National AIDS Strategy reflects the same mindset as the Swiss model and this approach is maintained in the Subcommittee report recommendations. For instance, the report discusses the dismantling of "barriers to the effectiveness of prevention measures" which are identified as "attitudes", "restrictions on the use of language" and "access to schools and residential facilities" (p. 27).

The report also discusses proposals by witnesses that advocate the "mandatory inclusion of sexual health programs in secondary schools" and that advocate the use of television education programs to inform children and adolescents about HIV/AIDS. For instance, the Canadian Foundation for AIDS Research (CANFAR) has funded and distributed the "AIDS Scare/AIDS Care" program to presidents of high school student councils across the country.

These "education" efforts with unknown behavioral implications have also extended to our young children. During the hearings, members of the Sub-Committee discussed the idea of distributing the "storybook" about HIV/AIDS - Come Sit by Me - to primary schools for children aged 4 to 8 across the country (pp. 30-31).

CONCLUSION

The Sub-Committee's report has failed to consider the issues of financial accountability, government intrusion and process related to its examination of the National AIDS Strategy. As legislators, we have the responsibility to properly weigh the options and consequences to preserve and enhance the health of all Canadians.

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