Report to the Federal Minister of Health: Consultative Committee for French-Speaking Minority Communities - September 2001

Health Canada
2001
ISBN 0-662-66037-4 (Print Publication)
Cat H21-176/2001

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Table of Contents

• Summary
• Introduction
• Health and Language
  • Federal Official Languages Act
    • Vitality of official language minority communities
    • Federal government's role in matters of health
  • Social context
    • Evolution of health care system
  • Importance of language
• Access to French-language Health Services
  • Current situation
    • More precarious health situation
    • Less access
  • Concept of accessibility and levers of intervention
    • Accessibility
    • Five levers defined by Committee
    • An effective strategy
• A comprehensive intervention strategy
  • Context
  • Guiding principles
    • Differential strategy
    • Action on supply and demand
    • Concerted effort
    • Action aimed at each lever
  • Five components of strategy
    • Networking
    • Workforce training
    • Intake facilities
    • Technology and strategic information
    • Research and awareness
  • Implementation of the initiatives
  • Funding
    • Existing mechanisms
    • Creation of new mechanisms for the full implementation of integrated initiatives
• Conclusion
  • Toward a better future
• Bibliography
  • Appendix A - List of CCFSMC members
  • Appendix B - List of studied regions
  • Appendix C - List of preliminary recommendations made in October 2000
  • Appendix D - List of preliminary recommendations made in April 2001
  • Appendix E - Progressive Classification of Specialized Health Cares
• List of Figures
  • Figure 1 Quality of Care and Language of Communication
  • Figure 2 Canada's French-speaking Communities at a Glance-1996 (According to Mother Tongue)
  • Figure 3 Concept of Access to Health Services
  • Figure 4 Relative Positions of Provinces and Territories According to the Major Phases of Health Service Development
  • Figure 5 Interrelationship between Demand and Supply
  • Figure 6 Elements of a Winning Approach
  • Figure 7 Progressive Classification of the Primary Health Service

Summary

Access to services in the user's language has benefits that extend far beyond simple respect for the user's culture. It is indispensable for improving the health status of individuals and for community empowerment in matters of health. Moreover, the importance of language increases when the services being provided are interpersonal rather than technical in nature.

As we shall see, the governments which provide health services to Canadians would gain by treating this issue as involving a cost-effective investment in population health, rather than an additional health spending item.

Accessibility is all the more important when a population's health problems are proportionately greater: studies on a number of determinants have shown that the health status of minority Francophones is generally poorer than that of their fellow citizens in any given province.

A number of minority communities already enjoy some health services in French, thanks to the efforts that several provinces have made, but there is room for improvement in all the provinces and territories. In fact, between 50 and 55% of French-speaking minority communities often have little or no access to health services in their mother tongue.

Our work has led us to conclude that there are important regional and local differences and significant disparities in service delivery. While some disparities can be explained in terms of Francophone numbers and population density, significant disparities have also been observed between regions which are seemingly comparable. Therefore, no single national approach would suffice.

Furthermore, it appears obvious that structures or mechanisms for greater empowerment or ownership of health by the French-speaking minority communities need to be implemented. These structures and mechanisms, which would fit within the framework of the current health care systems, would allow communities to determine their particular priorities and the best strategies for meeting them, which would inevitably translate into better access to health services. The nature of these mechanisms and the extent of this ownership obviously will vary according to the needs and capabilities of these communities. The empowerment could, for example, range from simply contributing to the definition of a health institute's directions to having full control over such an establishment, if not a complete network.

For these reasons, the Consultative Committee for French-Speaking Minority Communities (CCCSFM) recommends to the Minister of Health the adoption of a comprehensive strategy in order to enable the one million Francophone minority Canadians to improve their state of health, both individually and collectively, through better access to health services in their mother tongue. This strategy would include several initiatives that would have to be closely linked to form a consistent whole.

Objectives of the Recommendations

• To appreciably improve the level of access to health services in French for minority communities, particularly in the area of primary care;
• To develop a comprehensive strategy to permanently improve access to health services in French;
• To promote ownership of health by the communities;
• To establish a comprehensive strategy for continuous improvement of the accessibility of health services in French;
• To ensure that all the stakeholders work together to develop and implement strategies aimed at improving health services in each of the communities;
• To increase the number of Francophone health professionals who practice in minority communities;
• To take advantage of technology tools; and
• To gather reliable, relevant data on minority Francophone communities.

Summary of the Recommendations

1. Adopt a comprehensive intervention strategy to improve access to French-language health services.

All initiatives to improve the accessibility of French-language health services should be part of a comprehensive, coherent intervention strategy. This strategy should include five components: networking, infrastructure, work force initiatives, new technologies, and research.

2. Implement a community networking initiative in order to organize provincial and territorial networks as well as a national secretariat. These entities would provide a foundation from which to develop access to French-language health services.

Canada is a vast country and the French-speaking communities are dispersed throughout it. In addition, Francophones in the health field are isolated not only geographically, but also within each of the professional groups and the various associations. Networking can provide a means of linking the French communities, French-speaking health professionals, academic institutions, health facilities, and professional associations.

3. Support the establishment of a Francophone pan-Canadian consortium for the training of French-speaking health professionals.

At a time when needs are acute, there is a serious shortage of health professionals who speak French and enrollment numbers in health training programs are far too low. Moreover, communities will have difficulty in recruiting and training students in the health sector without joining forces and forming partnerships within a broader network. Thus, it is essential that a pan-Canadian consortium be developed to support training strategies. Such a consortium could be used to promote careers in health and to strengthen intake infrastructure in the communities for those who choose to enroll in college and university training programs in the health field.

4. Invest in health care infrastructures, to support the development of infrastructures and of intake centres to improve access to health services for French-speaking minority communities, based on relevant demographic and geographic parameters and the services in place.

Since between 50 and 55% of French-speaking minority communities have little or no access to health services in their mother tongue, the development of infrastructures for health care in French is a crucial part of improving access to French-language health services. Furthermore, the Committee believes that attempting to apply a single approach would be ill-advised since the challenges facing minority communities are varied in nature. The Committee believes that it would be more appropriate to implement solutions that could take into account the situation of each community.

5. Invest in development of the necessary technostructures for French-speaking minority communities.

In light of the national shortage of qualified professionals who speak French and the geographic dispersal of the 71 communities, innovative formulas are needed to better follow users of the services in the health system and to support the French-speaking professionals and improve their training.

6. Support the establishment, within the Canadian Institutes of Health Research (CIHR)-especially the Institute of Population and Public Health, of a chair or networking initiative among researchers of various postsecondary institutions to study the determinants of health of official-language minority communities and to examine their particular needs, increase other federal agencies' awareness (Statistics Canada, Human Resources Development Canada, Canadian Institute for Health Information, etc.) of the need to take linguistic and cultural factors into account and include them in their work, collect information to allow close monitoring of the health of official-language minority communities, and foster the development of these communities' internal research capabilities.

At the present time, data on the health status of minority Francophone communities is not sufficient to establish targeted health strategies at the local level. A dedicated chair and efforts to increase awareness in other federal agencies with regard to the linguistic and cultural aspects of their work would create a framework which is conducive to the gathering of relevant and reliable data on these communities, and would enable governments to target their interventions more effectively. Furthermore, if these communities could develop their own internal research capabilities, they could better define the objectives of their work, making the result even more relevant.

7. Ensure that French-speaking minorities have greater access to the various special programs and funds made available by Health Canada, and that these programs and funds best support the improvement of access to health services in French.

Through increased access to the various special programs and funds made available by Health Canada in such areas as research, health promotion and disease prevention, communities would have a greater ability to determine their needs, to communicate those needs, and to mobilize efforts to influence the supply of services.

Implementation of initiatives

In order to maximize the impact of the proposed strategy, it is important that these initiatives be implemented in an integrated and coherent way. First and foremost, it is essential that the networking initiative be launched since it aims at fostering the commitment of the communities and various stakeholders.

Once the networking initiative has been launched, it is essential to implement the other initiatives simultaneously since they are all closely linked.

Funding

New investments will be required to implement our recommendations and improve health care access for French-speaking minority communities. The scope of some of these investments, such as those required for networking, will be specific and exclusive to the French-speaking community, whereas other investments, such as the installation of new technologies in a given region or the recruitment of bilingual personnel, may increase the availability of some services to the region's population as a whole. Some investments can be gauged accurately at this point, while others will necessarily reflect communities' different absorption capacities and the varying rate of service development in communities.

In order to fund all of these initiatives, on the one hand, existing instruments could, as a transition, be used, such as the Primary Health Care Transition Fund (PHCTF) and, on the other hand, permanent specific funding mechanisms could be created to realize each component of the proposed strategy.

There are already several existing contribution programs (Health Canada or Canadian Heritage programs) that could be used as funding mechanisms. The federal-provincial agreement model already tested for the development of education in French could also be used.

Centre Medical Seine, Ste. Anne, manitoba

Introduction

The Consultative Committee for French-Speaking Minority Communities (CCFSMC) was established in the spring of 2000 to address issues of concern to the French-speaking communities. The committee is co-chaired by Hubert Gauthier, Chief Executive Officer of St. Boniface General Hospital (Manitoba), and Marie E. Fortier, Associate Deputy Minister, Health Canada.

... Mandate of the committee: to advise the Minister ...

The Committee is mandated to advise the federal Minister of Health on ways to enhance the vitality of French-speaking minority communities and to support their development, pursuant to the provisions of section 41 of the Official Languages Act.

... Composition of Committee ...

The CCFSMC is composed of:

• two co-chairs, one representing the community sector, the other representing the federal government;
• seven members representing French-speaking minority communities;
• three provincial government representatives (Manitoba, Alberta and New Brunswick);
• senior Health Canada officials with responsibilities in priority sectors; and
• a representative of the Department of Canadian Heritage.

The Committee's secretariat is provided, on the level of the federal government, by the Official Language Community Development Bureau (OLCDB), which is also responsible for vitality with respect to section 41 of the Official Languages Act within Health Canada. On the community level, this role is performed by the Fédération des communuautés francophones et acadienne du Canada (FCFA).

... Access to French-language services: a priority for the Committee ...

Early in its work, the CCFSMC realized that its priority should be the issue of access to French-language health services. Accordingly, the Committee has focused as a priority on primary care which aims at such services as promotion, prevention, health care and rehabilitation, and which constitutes the first stage in the health care services continuum and represents probably the most frequently used level of health services. Moreover, this choice fits in well with the priorities that the Prime Minister and the premiers of the provinces set for themselves at their September 2000 meeting.

The CCFSMC held its first meeting in June 2000. On that occasion, the members resolved to assess the current situation in the various communities in order to gain a better understanding of the issues and to outline possible solutions.

... Activities of the committee ...

During the summer of 2000, Health Canada made a large financial contribution to the FCFA, enabling the latter to co-ordinate a major study on access to French-language health services and to identify levers likely to be of assistance in improving the accessibility of those services. The study, entitledImproving Access to French-Language Health Services, was published in June 2001. Its main points have been incorporated into this report. (For example, most of the diagrams included in this report are derived from the FCFA study.)

The CCFSMC asked the authors of the study to propose possible solutions with respect to service organization and related implementation strategies, as well as to ensure integration of the proposals into the present or projected systems of service delivery at the provincial/territorial level.

At its second meeting (October 2000), the Committee reviewed the work accomplished to that point and formulated interim recommendations to the federal Minister of Health (these recommendations are presented in Appendix C). It was at this point that the Committee began meeting with the Health Canada program officials and the community representatives to inform them of its work and obtain their comments on various issues.

In December 2000, the committee discussed the initial conclusions of the study and compared them with its own findings. It met again in January 2001 to examine the findings which were emerging from the FCFA-coordinated study and to form working groups, each of which was mandated to examine in depth one or more levers of intervention likely to improve the accessibility of French-language health services and to submit their recommendations to the Committee. The groups established included the Networking Group, the Training and Research Group, and the Infrastructure, Service delivery and Technology Group.

In March 2001, the FCFA submitted a draft of its study entitled Improving Access to French-Language Health Services. The study presents an overview of the current situation and advances a number of innovative ideas for improving the quality of health care for the one million minority Francophone Canadians. Furthermore, the Committee made modifications to its preliminary recommendations (Appendix D provides a list of the modified recommendations).

At their fifth and sixth meetings (April and June 2001), the committee members analyzed the study, as well as the reports of the working groups, and discussed the content of the final report to the Minister.

Centre de santé communautaire de I'Estrie's branch located in Crysler, Ontario

This Report

... Access to services in French : a real problem ...

This report explains the factors which account for the present urgent need to take action and proposes a number of solutions to address the important national challenge of improving the accessibility of French-language health services for the French-speaking minority communities. In fact, between 50 and 55% of French-speaking minority communities seldom or never had access to services in French, whether it be in private clinics, in hospitals, in health community centres or others.

... A favourable context ...

The current environment is particularly conducive to a service improvement initiative. Indeed, two key commitments made by the federal government in its January 31, 2001, Speech from the Throne go to the very heart of the issues which the Committee has examined:

• The Government of Canada, for its part, will focus on creating a more inclusive society [...] where quality health services are available to all, and where Canadians enjoy strong and safe communities. ¹
• Canada's linguistic duality is fundamental to our Canadian identity and is a key element of our vibrant society. The protection and promotion of our two official languages is a priority of the Government - from coast to coast. The Government reaffirms its commitment to support sustainable official language minority communities and a strong French culture and language. And it will mobilize its efforts to ensure that all Canadians can interact with the Government of Canada in either official language.²

As a number of international studies have clearly shown, the delivery of services in the language of a population is an essential part of improving health conditions and fostering community ownership in matters of health. It is also closely linked to the workers' ability to provide care, as well as to advise, guide and educate people.

... Language determines the quality of service ...

The efforts and resources that go into renewing the provincial and territorial health care systems in the coming years will create an opportunity to improve the accessibility of health services in all parts of Canada for populations facing special challenges as a result of their minority status.

Interestingly, many of the innovations contemplated by the provinces and territories are designed to strengthen the ability of communities to prevent and treat health problems. The implementation of these innovations will require better integration of the various elements, such as front-line services, prevention, screening, health information, diagnosis, rehabilitation, short-term care, specialized and highly-specialized services, and long-term care. The innovations contemplated are also designed to establish a continuum that encompasses far more than curative forms of care.

If they have the necessary means at their disposal, Francophone Canadians will therefore have an excellent opportunity to participate in a promising, more inclusive approach, because, even in the communities where Francophones are most heavily concentrated, resources aimed at Francophones are in short supply.

There is a growing realization that the viability and efficacy of our health systems are dependent on genuine collaboration between the principal partners. For example, the model put forward by the World Health Organization (WHO), entitled Towards Unity for Health, identifies five principal partners: health professionals, managers (including those from health institutes), policy makers, academic institutions and communities.

... Importance of genuine collaboration ...

In this model, optimal health system performance leading to improvements in population health requires a concerted effort on the part of all partners.

In the WHO model, the community has a particularly crucial role to play. In the area of training, for example, the contribution of the community can take various forms: it can provide places for learning and offer students the opportunity to deal with real-life situations; it can also provide educational institutions with necessary feedback, thus enabling them to adjust their programs to the needs of populations. Individuals can also play a role through direct involvement in training programs.

In this respect, the Acadie-Université de Sherbrooke partnership for medical training in New Brunswick offers an excellent example of how Francophone communities can make a significant contribution toward the improvement of the health system. What it best illustrates, however, is the importance for communities of having their own decision-making frameworks to enable them to make choices based on their own needs and priorities.

The renewal of our health systems offers a context which is particularly favourable for the implementation and consolidation of initiatives that will enable Francophone communities to organize and co-ordinate French-language primary care services and to facilitate their integration. The challenge lies in making the most of the opportunities afforded by the envisaged reforms, in order to carve out a space for French-language health services at the local and regional levels, with the participation of governments and other partners of Francophone Canada. It is precisely that which we recommend be done by the various partners capable of changing the health services situation for the French-speaking minority communities.

Clearly, the nature and scope of this "space" will vary according to the capacities of the various communities. However, one of the key concepts underlying all the ideas presented in this report will be relevant for all communities - namely, the need to promote greater community ownership in matters of health. In taking ownership, the communities will have to develop, within the current health networks, frameworks or mechanisms that will enable Francophones to identify their own priorities and to determine the best strategies to achieve them and to have better access to health services. The empowerment could, for example, range from simply contributing to the definition of a health institute's directions to having full control over such an establishment, if not a complete network.

The first hospital in Western Canada

Health and Language

Federal Official Languages Act

Vitality of official language minority communities

In 1988, the federal government revised the Official Languages Act, adding section 41, which deals with the government's commitment to enhance the vitality of the French and English linguistic minority communities in Canada, supporting and assisting their development and to foster the full recognition and use of both English and French in Canadian society.

... A commitment toward official language minority communities ...

In making this commitment, the federal government was seeking to ensure that the key federal departments and agencies would participate in fostering the development and vitality of the official language minority communities. Since that time, the federal government, through its departments and agencies, has applied section 41 in a number of concrete ways. In 1994, it approved the establishment of an accountability framework in this connection which relates to the economy, human resources development and culture. This framework requires that designated departments and agencies produce an annual or multi-year plan of action, after consulting with the communities regarding their individual needs. It also requires that designated departments and agencies draft achievement reports.

Federal government's role in matters of health

The federal government, the ten provinces and the three territories each play strategic roles on their own level in determining health policy in Canada.

The federal government's roles are to establish and administer the national standards or principles connected with the health care system, to contribute to the funding of provincial health services through tax transfer payments, to oversee the direct delivery of health services to certain groups (veterans, Aboriginal persons living on reserve, and military personnel), and to perform certain health-related functions such as health protection and health promotion.

Potential federal interventions on behalf of official language minority communities could take place only in partnership with the provinces and territories (the service providers) and the communities themselves, in a spirit of co-operation.

Social context

Evolution of health care system

... Provincial and territorial reforms ...

One of the key events of the last decade has no doubt been the adoption of provincial and territorial reforms designed to optimize the health services offered to citizens. The main motivation behind these reforms has been a desire to make the system more effective and to reduce system costs. However, the reforms are also designed to take advantage of the remarkable technological advances of the late 20th and early 21st centuries.

... Social union: a new partnership ...

The 1999 Social Union Agreement between the federal government and the provincial and territorial governments is another event which has had a direct impact on the health system. This agreement describes a new partnership between the different levels of government, as well as a new framework for government efforts to renew and modernize social policy in Canada. The agreement emphasizes the pan-Canadian dimension of our health systems and social programs.

... Prime Minister and premiers Meeting of September 11, 2000 ...

In September 2000, the Prime Minister and the provincial premiers entered into an agreement on health services. This agreement, which will speed the implementation and broaden the scope of health reforms, provides for $2.3 billion dollars for priority health issues, including $1 billion for the acquisition of medical equipment, $800 million for the Primary Health Care Transition Fund (PHCTF) and $500 million for the development of health information systems.

Importance of language

Providing quality health services goes beyond the technical acts involved in providing people with care. Quality is, in fact, closely tied to the ability of the workers to assist, advise, guide and educate the service users. The ability to understand and to be understood is therefore a crucial part of an effective relationship between health professionals and users of health services.

... Language is an important component of effective care ...

The service user's access to health services in his or her own language means far more than simply respect for that person's culture: it is, at times, indispensable for improving health and for people's taking ownership of their own health. A number of studies have confirmed that language is a key factor in the effectiveness of certain forms of care. They also support the conclusion that language barriers:

• reduce use of preventive services;
• increase the amount of time spent on the consultation, the number of diagnostic tests ordered, and the probability of confusion in the diagnostic and treatment process;
• affect service quality in situations where effective communication is crucial (for example, in the case of social services, physiotherapy and occupational therapy);
• decrease the probability of compliance with treatment; and
• reduce satisfaction with the care and services received by the service users.

Centre de santé communautaire de l'Estrie

The following figure illustrates two critical dimensions of the relationship between health service quality and the language of the service user.

... Two critical dimensions for health ...

This figure shows that a patient's language of communication is all the more important when the service being delivered is interpersonal or psychosocial, rather than technical or biomedical, in nature. Generally, primary care services are concentrated in the upper portion of the diagram, where language of communication increases in importance, whereas tertiary care services are primarily situated in the lower portion. This analytical framework is useful when examining the accessibility of services in a given region, as well as for determining priorities with respect to possible local initiatives. Even services which are apparently biomedical can include numerous language transactions in the broad continuum of services. Take, for example, a Francophone who goes to see his family doctor for a routine check-up. During the visit, which takes place in French, the doctor notices a digestive system problem. He therefore decides to refer this person to a specialist. The specialist confirms the family doctor's diagnosis and refers the person to a surgeon. The surgeon does the appropriate surgery. Once the surgery is over, the patient consults a Francophone nutritionist in order to change his diet and adopt a healthier lifestyle.

... Continuum of services ...

Figure 1 Quality of care and language communication

Access to French-Language Health Services

Current situation

More precarious health situation

... Francophones in French-speaking minority communities more likely to have health problems ...

Studies of certain French-speaking minority communities have shown that the Francophones are in poorer health than their Anglophone counterparts.

In Ontario, for example, a study ³ revealed that a smaller proportion of Francophones than of Anglophones described their state of health as "excellent."

Another Ontario study, on the prevalence of diseases, revealed that the rates of certain diseases (respiratory disease, hypertension, musculoskeletal problems) for Francophones were higher than those recorded at the provincial level. ⁴

A study ⁵ conducted in New Brunswick found that, once geographical factors were taken into account, the variable of language was a discriminating factor in the health status of the province's populations. Francophones in northern New Brunswick had the highest rates of institutionalization and hospitalization in the province. According to the authors of the study, Anglophones in the northern region enjoyed more favourable conditions.

Even though they are piecemeal, these conclusions reflect what would be predicted with a health determinants approach, an approach that establishes a close link between socio-economic conditions and health. Clearly, then, the accessibility of health services is of greater importance to a population that faces more health challenges.

It was in this context that the authors of the FCFA-coordinated study on access to French-language services painted a global sociodemographic picture of 71 French-speaking minority communities. (A complete list of the communities studied is provided in Appendix B.) To do this, they first designed a data collection form and an interview form, and determined which communities would be studied and which persons should be interviewed. Next, they gathered data on the situation in all the provinces and territories and interviewed more than 300 persons, who were chosen for their knowledge of the situation or for where they were situated on the public health scene.

Since it is generally acknowledged that the indicators of a precarious health situation are associated with more precarious socio-economic conditions, the authors of this study emphasized certain socio-economic factors in connection with the French-speaking communities and compared them with the data currently available on Anglophones. They learned:

• that the French-speaking minority communities are scattered across the country; (The following figure gives the number of Francophones in each province and territory and indicates the percentage they represent of the overall population of that province or territory.)
• that the members of these communities are generally older than the members of the English-speaking majority communities;
• that they have less education than the Anglophones; and
• that there are fewer of them in the labour force than there are Anglophones, but that their average income is similar to that of the Anglophones.

Figure 2 Canada's French-speaking communities at a glance-1996 (According to mother tongue)

Source: Statistics Canada

Note: Some agencies and experts believe that Statistics Canada's method underestimates the number of Francophones in each province and territory. Based on their formula, the number of Francophones would in fact be 5 to 10% higher.

This sociodemographic portrait of the French-speaking minority communities reveals two important things - namely, that the health situation of the members of these communities is more precarious ⁶ and that there are significant regional differences between the various communities. This heterogeneity points to a need for a large flexibility in initiatives aimed at improving accessibility. ⁷

... More precarious health and heterogeneity of communities ...

Less access

... Two observations ...

For the 71 communities studied, there are significant disparities between the levels of access to French-language and English-language services. In fact, English-language services are three to seven times more accessible. ⁸ Through its work, the Committee has arrived at two important observations:

• There are significant regional differences. While some of the disparities observed can be explained in terms of Francophone numbers and population density, there are also significant gaps between "comparable" regions. ⁹ Other important factors are thus clearly influencing accessibility.
• There are potential improvements to be made everywhere. Although Francophones in some regions enjoy a relatively higher level of access to French-language health services, there is always room for improvement. No region can claim to have achieved its full potential. Naturally, the improvements that are possible will vary from one region to another, since the various communities do not all face the same challenges, nor are they all starting from the same point.

Concept of accessibility and levers of intervention

Accessibility

... Definition of accessibility ...

Before continuing our examination of access to French-language health services, it is important to agree on what "accessibility" means. In Webster's Ninth New Collegiate Dictionary, "accessibility" is listed under "accessible," which is defined as, among other things, "capable of being used" and "capable of being understood." ¹⁰ These two different meanings correspond perfectly to the Committee's aims. Thus, the concept of accessibility of health services is understood to refer to the possibility of obtaining health services (availability) in French (understanding).

Five levers defined by Committee

The CCFSMC promotes an approach that is intended to strengthen the ability of communities to prevent and treat health problems. Proposed initiatives must therefore seek to foster a greater integration of such things as front-line services, prevention, screening, health information, diagnosis, rehabilitation, short-term care, specialized and highly-specialized services, and long-term care. Initiatives must also promote the development of a continuum of care, on the basis of a comprehensive approach to health which encompasses more than simply curative forms of care and places particular emphasis on the determinants of health and on the effects of the living environment of individuals, families and communities.

The following levers have been identified:

• networking - to facilitate and promote community involvement and to facilitate access to Francophone professionals;
• training - to ensure that bilingual professionals are available in the short, medium and long terms;
• intake centres - to bring together health professionals and direct French-speakers to facilities where their language is spoken, facilities where there is a physical, visible and tangible manifestation of active offer of health services in French;
• technology - to strengthen the relationship between the patient and the professional through telemedicine and calls centres, to facilitate consultations among professionals and to ensure maximum use of the computerized data on the patient's health; and
• information - to assist stakeholders in establishing priorities in the area of French-language services, as well as to direct users to the available French-language resources and to facilitate management of their health.

Centre de santé communautaire de l'Estrie's branch located in Alexandria

The following figure illustrates the various elements which make up the concept of accessibility. For each community, it is necessary to determine which elements of the concentric circles should be adopted as priorities, without neglecting the other elements, since all of them are interrelated. In addition, the specific characteristics of the province in which each community is found must be taken into consideration, since the efforts made must fit within the framework of the current health systems in each province.

Figure 3 Concept of access to health services

An effective strategy

...Strategic assumptions...

An effective accessibility strategy requires that certain prerequisites be ... Strategic satisfied. These prerequisites have been grouped under four strategic assumptions:

• the need to act as much on supply as on demand;
• the need for joint action;
• recognition of regional differences; and
• the importance of community participation.

Our survey of the current situation and of initiatives presently underway has highlighted the importance of addressing both supply and demand and of doing so simultaneously. The institutions and government authorities responsible for the supplying of health services must be supported in their francization efforts and encouraged to energetically overcome the obstacles which stand in their way. A proactive approach to the supplying of French-language services is essential to improving those services, since individuals who are already in a state of vulnerability cannot be asked to call for French-language services. As well, Francophone citizens and communities must be encouraged to express their needs clearly and actively participate in the management of their own health.

Moreover, the accessibility of French-language health services will be improved more quickly if the efforts in training and health are based on joint action by five stakeholder groups: health professionals; health managers (including those from health institutes); policy makers, academic institutions and communities. A significant and on-going commitment on the part of the stakeholders in these groups is needed in order to reduce the obstacles which impede efforts to improve access.

It is also important to recognize that actual and potential access to health services in French vary considerably from one region to the next. As a result, proposed approaches must take into account the individual characteristics of the communities being targeted.

Finally, experience has shown that the greater the presence of Francophones within the decision-making and governance structures of health institutions the greater the respect for the place of the French language and the greater the reflection of the French language in service delivery, which contributes to the development and enhancement of French-speaking minority communities. In conclusion, it is important that Francophones be present in the decision-making structures and that they be able to play the greatest possible role in governing their health services, since linguistic minorities cannot be certain that the majority will take all of their linguistic and cultural concerns into account in the decision-making process.

Notre-Dame Hospital, Hearst

Comprehensive intervention strategy

Context

Certainly, a number of initiatives designed to improve the quality of French-language health services have been undertaken, be it by provincial or territorial governments or by regional boards of health. For example, there is the Évangéline Community Health Centre in Prince Edward Island, the French-language community health centres in Ontario, the program of the national health sciences training centre at the University of Ottawa, the St. Boniface community health centre and the French-language health program in Alberta's Peace River region.

The efforts made by these organizations not only deserve to be supported, but also must be multiplied and extended, this within the framework of a comprehensive strategy designed to provide the one million Francophones in French-speaking minority communities with quality services.

... Umbrella recommendation ...

That is why the Committee recommends that Health Canada implement a strategy aimed at activating and, at the same time, integrating the five levers defined above. Moreover, to be truly effective, a strategy such as this must be based on certain guiding principles.

Guiding principles

Differential strategy

As we have stated a number of times, the five-year initiatives proposed in this report will have the same general goal, which is to improve access in all communities. However, the starting point and end point for years zero and five respectively will vary from region to region.

The following figure presents the current situation as it relates to the three major phases in the development of French-language services. It illustrates well the relative position of the various provinces and territories in Canada.

Figure 4 Relative positions of provinces and territories according to the major phases of health service development

The awareness phase is the phase in which Francophones, their communities, health professionals, existing institutions, and government authorities develop an awareness of the issue of French-language services. The structuring phase is the phase in which there is sustained development of the supply of French-language services. It is during this phase that the supply of services becomes structured and institutionalized. The consolidation phase is focussed on protecting the ground that has been gained and on adapting to new technologies and new ways of doing things.

A similar chart could be constructed for each of the provinces. Such a chart would show that some sub-regions are still in the awareness phase, while others are in the structuring phase, and still others are approaching the consolidation phase.

Figure 6 (pg. 21), shows that the improvements needed vary from one region to the next. Consequently, the same solution cannot be applied to all 71 communities. What is needed is a sufficiently flexible differential strategy which takes regional differences into account.

Action on supply and demand

The initiatives underway are enabling us to see the importance of working on the supply of and demand for services simultaneously. Ignoring one dimension makes the job much harder and the results much more uncertain. The following figure shows the interrelationship between the supply of and demand for French-language services.

Figure 5 Interrelationship between demand and supply

To stimulate supply, it is important to help the health services providers be proactive and to ensure that the health institutions' officials support the communities' initiatives and that the government authorities recognize that the communities' demands are legitimate. The governments have an obligation to create a climate, a situation, in which the members of each of the official language communities can be born, be cared for and die in their own language. Given the vulnerability of ill patients, the supply is an important aspect to consider in improving access to health services in French.

To stimulate demand, it is important to increase the Francophones' awareness of the use of French-language services. Many Francophones hesitate to express their needs in their own language. How many content themselves with inferior service, with a situation in which they do not feel understood by a health professional or they do not properly understand the advice or instructions given by the health care personnel?

In short, if the service providers are not proactive, if the institutions' officials do not support the communities' initiatives, if the government authorities do not recognize the legitimacy of the Francophones' demands, it will be difficult to respond to the demand. Moreover, if Francophones hesitate to express their needs, if the community does not value the efforts made by the health professionals, if the Francophones' associations do not place priority on health matters, it will be difficult to move the supply of services in the desired direction.

Concerted effort

As we saw earlier, improvement of the accessibility of French-language health services will be more effective if it is based on concerted efforts on the part of the three main groups of stakeholders (communities, institutions and political authorities). The figure presented below illustrates this dynamic.

Figure 6 Elements of a winning approach

Community involvement: The community must recognize the importance of French-language health services. It must increase its awareness, identify needs, and express and promote those needs. It must organize itself to influence the supply of services and it must acquire the means to achieve its goals with respect to the accessibility of French-language health services. Moreover, the increased role of the communities in the health sector becomes more possible as this sector decentralizes and continues to do so. Greater Francophone community involvement in the management of French-language health services and the creation of circumstances fostering community development are both made possible by this trend.

Appropriate institutional structure refers to the implementation of more formal planning, coordination and delivery mechanisms. These mechanisms may be highly developed in some jurisdictions, whereas a significant amount of work to strengthen these structures may be required in many other regions. Since the institutional structures for the Anglophone majority do not always allow the particular needs of Francophones to be recognized and met, structures or mechanisms fostering greater empowerment or ownership by French-speaking minority communities must be implemented within the framework of the current health networks. Thus, these communities could determine their priorities and find the best strategies to achieve them, improving access to health. The nature of these mechanisms and the extent of this ownership obviously will vary according to the needs and capabilities of these communities. The empowerment could, for example, range from simply contributing to the definition of a health institute's directions to having full control over such an establishment, if not a complete network.

Political will: This term refers to a government's commitment, through policies, legislation and regulations that reflect recognition of the importance of accessible French-language services for French-speaking minority communities. In order to ensure the relevance and success of government initiatives, it is important to engage the communities in the planning and realization of these initiatives.

Since the situation of each community is unique, emphasis needs to be placed in some cases on community involvement, in others on institutional structures or political will. In some communities, it may be necessary to focus on two or all three of these aspects at the same time.

Action aimed at each lever

Every initiative to improve the accessibility of French-language health services has its merits. However, an effective strategy will require that all the initiatives overlap and that they be implemented simultaneously in a way that reflects local realities and the demographic characteristics of the communities.

Five components of strategy

Networking

... Geographic dispersal of Francophones ...

Canada is a huge country and the French-speaking communities are scattered across it. There are Francophones in all the provinces and territories of Canada. However, the relative importance and level of concentration vary significantly from one administration to another.

... Health: a highly compartmentalized field ...

Since health is a relatively compartmentalized field, the Francophone professionals are isolated, not only from one another because of their profession, but also, as a minority group, within each of the groups and associations. It is very difficult, perhaps even impossible, to significantly improve the situation of French-speaking minority communities if the individual parties work in isolation, in silos.

If the French-speaking communities, the Francophone health professionals, the health institutions, the professional associations and the educational institutions were able to network with one another, there would be better circulation of French-language health information and the geographic dispersal of the communities and the isolation of the Francophone professions could be countered. It would also be possible to promote greater cooperation and more effective use of human resources and to better meet the communities' needs. In addition, it would become possible for the French-speaking communities and professionals to influence the decision-making processes of the health institutions, and that could lead to better access to services in French.

... Recommendation on Networking ...

The Committee recommends that Health Canada implement a networking initiative involving the creating of approximately twenty provincial and territorial networks and a national secretariat. These entities would provide a foundation from which to develop access to French-language health services. The provincial and territorial networks could, among other things, establish strategies to improve French-language health services, promote commitment on the part of the communities, define local needs, carry out promotion and prevention activities, promote careers in health, and promote the grouping together of health professionals. The mandate of the national secretariat would be to coordinate efforts undertaken at the regional level to improve access to French-language services. The national secretariat would facilitate information sharing among the various networks, provide technical support to the regional networks, and represent the interests of these networks in its dealings with national stakeholders.

The networking would lead to the creation of concrete and lasting links between the various stakeholders. It would encourage greater community ownership and bring individuals and institutions into contact with another for planning, developing, strengthening or maintaining initiatives promoting better access to French-language health services. In short, this initiative would make it possible to counter the geographic dispersal of the French-speaking communities and the isolation of the French-speaking professionals, make better use of existing resources, gain a better understanding of the communities' needs, and facilitate co-ordination and follow-up in health matters, thereby bringing greater momentum to efforts to improve French-language services.

Workforce training

... A serious shortage ...

In Canada there is currently a serious shortage of professionals able to serve the French-speaking minority communities in French. Moreover, the number of enrollments in health sector training programs is too low to meet these communities' crying needs. Indeed, the enrollment numbers would have to triple, if not quadruple.

... Francophone health-sector students are being uprooted ...

Members of the French-speaking minority communities who wish to study in French in a given academic health discipline frequently have to travel to another city or province to do so. Once they have been uprooted, few return to their communities to practice their profession. The other option available to these individuals is to do these studies in the health field at the nearest English-language institution. Few who choose this route ultimately practice their profession in French and fewer still return to practice in their home communities. Studies from the WHO, and the "World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians" (WONCA) and the experience of the Acadie-University of Sherbrooke Partnership have shown that there are two success criteria for recruiting and retaining health professionals: the candidates' home region and their exposure to their home region as early and as often as possible during their training. It is therefore important to strengthen training for French-speaking students as near as possible to their home communities, in order that they may subsequently practice their profession in their own communities and in French.

It is important to find a solution that will address the shortage of French-speaking health professionals, increase training capacity in order to better meet the needs, and ensure that Francophone health professionals can work in their own language and in their communities of origin.

... Recommendation on workforce training ...

Therefore, if the Committee recommends that Health Canada support the implementation of a pan-Canadian consortium for the training of French-speaking health professionals. This national network would be composed of several postsecondary institutions (e.g. the Université de Moncton, the University of Ottawa, the Université de Sainte-Anne, Laurentian University, the Collège Saint-Boniface, the Faculté Saint-Jean, and the Acadie-University of Sherbrooke Partnership), community partners and health institutions in the communities. Its role would be to implement strategies to recruit and train future health professionals specifically to implement training programs tailored to the needs of the communities in which they are found. Among other things, it would provide training for students, promote careers in the health field in order to increase enrollment and ensure that the necessary intake infrastructure is in place at the community level to accommodate students who wish to enroll in a French-language university training program in health.

The current National Health Training Centre (NHTC), which is in Ottawa, was created thanks to funding from Canadian Heritage. So far, it has produced excellent results. For example, during the first nine months of its existence, it increased by 23% its intake capacity in medicine and by 5% its intake capacity in 11 other programs, including nursing. CCFSMC believes that it is necessary to put in place a new structure that would make it possible to better respond to the communities' needs, since keeping students in their environment and returning newly trained personnel to the communities are the two essential elements to solving the current problem.

In this context, it deems it essential that training efforts be guaranteed and increased by encouraging the creation of a consortium, which would make it possible to have greater health-sector training capacity and to ensure that future French-speaking health professionals are able to work in their home community and in their own language.

Intake facilities

... Under-utilization of preventive services ...

Since they seldom or never have access to health services in their own language, members of the French-speaking minority communities tend to under-use prevention services and to over-use curative services.

... Importance of primary care ...

Clearly, one wishes that every Francophone community could have access to all health services - even highly specialized care - in French. However, to improve health services in French, the Committee has chosen to emphasize primary care, which is the first level of contact with the health system and is the sector that provides solutions to the main health problems. By improving the accessibility of primary care, one would be taking action on the level on which communication between the service user and the physician is very important. Obviously, this is a matter of priority. Thus, where primary services are well developed, the focus should be on specialized care.

The Committee believes that taking a single approach would be ill-advised, since the communities do not all face the same challenges. It believes that it would be more appropriate to implement solutions that could be adapted to reflect the situation in each community. Having concluded that there is a continuum, a logical progression, for the development of French-language health services, the Committee has identified 6 models of primary care delivery and 11 models of specialized care delivery within this continuum. The following figure illustrates the primary care continuum, which ranges from single service delivery and provision of services by call centres to the delivery of services by formal multidisciplinary groups. (Consult Appendix E for the 11 models of specialized care delivery.)

Service Delivery Approach

In order to make primary care more accessible it would be appropriate to identify the service delivery model best suited to each community, taking into account the demographic and geographic parameters, as well as the services currently in place, and then to examine how the development of infrastructure will fit in with provincial efforts to restructure primary care. The next step would be to identify the human, material and information resources needs of each community and to ensure optimal integration of communities' needs in local and regional services. The objective would be to enable all the communities to have, each on its own level, better access to French-language health services. The objective would then be to allow all of the communities to have, each at their own level, better access to health services in French, which would have positive repercussions on the entire Canadian population.

... Infrastructure recommendation ...

The Évangéline Community Health Centre is a very good illustration of the fact that language minority communities can be provided with health services, even when the numbers of Francophones is small. In Figure 9 above, the Evangeline centre would be at level 5b.

The Committee therefore recommends that Health Canada provide financial support for the development of infrastructures and intake centres to improve access to health services for French-speaking minority communities, based on relevant demographic and geographic parameters and the services already in place. This would help to reduce the amount of time spent on each consultation with a Francophone patient, as well as the number of diagnostic tests ordered and the likelihood of confusion in the diagnostic and treatment process. Service quality would be improved and the probability of treatment compliance would increase.

 

Technology and strategic information

New and promising technologies ...

The St.Boniface Hospital

Given the nation-wide shortage of qualified professionals who speak French and the geographic dispersal of the 71 communities, innovative formulas need to be found that would make it possible to follow the services user through the health care system. Although they are still not well-known, the new technologies hold considerable promise.

It would be possible to provide home telecare (that is, use of information and communication technologies for provision of home care) in French. It would also be possible to create technostructures that give Francophone health professionals virtual access to the services found in large Francophone urban centres (such as Montreal, Sherbrooke and Winnipeg) and to put in place telemedicine and teleradiology services. In addition, it would be possible to create electronic medical records in French only, in order to stimulate the offer of services in that language and call centres could be set up.

... Technology recommendation ...

The Committee therefore recommends that Health Canada invest in development of the technostructures for French-speaking minority communities.

Research and awareness

... Little data on the communities as a whole ...

There is, at present, insufficient data on the French-speaking minority communities as a whole and on people's health in those communities. This makes the efforts to develop and implement proactive strategies more complex. Data that would illustrate the health of people in the communities, show how they are treated under provincial health care systems and indicate which services provided to them, would be essential to better determine the middleterm and long-term needs of these communities and to establish more targeted strategies.

... Research and awareness recommendation ...

The Committee therefore recommends that Health Canada support the establishment, within the Canadian Institutes of Health Research (CIHR)-especially the Institute of Population and Public Health, of a chair or networking initiative among researchers of various post-secondary institutions to study the determinants of health of official-language minority communities and to examine their particular needs, increase other federal agencies' (Statistics Canada, Human Resources Development Canada, Canadian Institute for Health Information, etc.) awareness of the need to take linguistic and cultural factors into account and include them in their work, collect information to allow close monitoring of the health of officiallanguage minority communities, and foster the development of these communities' internal research capabilities. In doing so, Health Canada would establish a framework through which the federal government could provide the provinces with relevant, reliable data on the French-speaking minority communities - a federal responsibility - and establish strategies that would be more targeted, in order to help these communities flourish and develop. In addition, by developing their internal research capabilities, the communities could have a greater impact on works and contribute to the production of even more useful conclusions. Better still, the communities should take ownership of their own health, which would contribute to their development and enhancement.

Implementation of the initiatives

The implementation of the initiatives under the proposed strategy should be carried out in an integrated and consistent manner. In order to derive the maximum benefit from the proposed strategy, it will be important to find ways of encouraging the commitment of the communities and of the various stakeholders. This is why the Committee believes that networking should be the first focus of the strategy. This would serve to promote interaction among the various stakeholders and the French-speaking communities, and would increase community involvement. It would also make it easier to define the needs of the various Francophone minority communities and to support their promotion and prevention efforts.

Once the networking initiative has been launched, it is important that the other initiatives be implemented simultaneously-workforce recruitment and training, the implementation of intake infrastructures for primary care as a priority, the implementation of technostructures, research and awareness, and improved access to specialized Health Canada programs and funds-since these components are closely linked and together they would create a leverage effect strong enough to produce the desired change.

Funding

New investments will be required to implement our recommendations and improve health care access for French-speaking minority communities. The scope of some of these investments, such as those required for networking, will be specific and exclusive to the French-speaking community, whereas other investments, such as the installation of new technologies in a given region or the recruitment of bilingual personnel, may increase the availability of some services to the region's population as a whole. Some investments can be gauged accurately at this point, while others will necessarily reflect communities' different absorption capacities and the varying rate of service development in communities. In the light of these considerations, our work will enable us to provide the following estimates: The operation of Francophone community networks capable of uniting the various partners needed to plan, develop and support French-language health service delivery will require approximately five million dollars annually. Federal, provincial and territorial health ministers agreed in September 1999 on the need for appropriate action to meet the challenge of ensuring the availability of sufficient, reliable and affordable health care resources, including physicians and nurses. The training and recruitment of qualified French-speaking and/or bilingual personnel in the various health care disciplines should certainly be included, at least in part, among the efforts planned by the various levels of government. Furthermore, the type and level of investments will depend on the current absorption capacity of existing institutions as well as their ability to attract recruits.

We can anticipate, however, that some fifteen million dollars in government funds will be required each year for training. In the first years, the establishment of a French-language training network will be included in these funds. & The gradual establishment of a health infostructure to serve Frenchspeaking minority communities could grow to as much as twenty million dollars. The establishment and maintenance of infrastructures where Francophones will be able to obtain primary care in French will require an estimated annual investment of about twenty-five million dollars. This estimate includes transition period costs. Insofar as the establishment of these infrastructures will necessarily lead to a shift in Francophone demand toward these centres, the expenditure involved cannot be considered entirely new. To finance all of these initiatives, currently available mechanisms must be used and new instruments must be planned.

Existing mechanisms

... IPOLC and PHCTF as a resource ...

In order that the priority initiatives may be implemented as quickly as possible, the Committee suggests using, as a transition, mechanisms that are currently available, namely the PHCTF (Primary Health Care Transition Fund). The Committee also believes that French-speaking minority communities should have greater access to the various federal health promotion and prevention programs and to special funds made available by Health Canada (Population Health, InfoHealth, research, etc.). This mechanism could be complemented with the Interdepartmental Partnership with Official-Language Communities (IPOLC) between Health Canada and Canadian Heritage. In addition, the Committee recommends that these programs and funds be used to a greater extent to support effort to improve access to health services in French. Through increased access to the various special funds and programs made available by Health Canada in such areas as research, health promotion and prevention, the communities would have a greater ability to determine their needs, to communicate those needs, and to mobilize the efforts to influence the supply of services.

... Health related federal programs and funds recommendation ...

Creation of new mechanisms for the full implementation of integrated initiatives

Although it is possible to use existing financial resources, they will not be sufficient to implement the proposed strategy. In addition, the mechanisms available to the government have more general goals. Thus, the Committee suggests creating permanent specific funding mechanisms, such as a community action program targeting French-speaking minority communities, with dedicated resources, and a special envelope under the Canadian Health Infostructure Partnerships Program (CHIPP). Other mechanisms could be duplicated in the same way with dedicated envelopes. Another approach would be to negotiate federal-provincial-territorial agreements dealing with proposed strategy and the associated costs. The combination of several approaches could also be considered after further consultations with the provinces and territories as well as the targeted communities.

Conclusion

Toward a better future

Since last November, the Committee has organized a number of awareness sessions to highlight the importance of improving access to French-language health services. It has also submitted preliminary recommendations to the federal Minister of Health (who accepted them) and has presented its work and recommendations to the provincial and territorial deputy ministers of Health and Francophone affairs. In the coming months, the Committee will present its work and recommendations to the provincial and territorial ministers of Health and Francophone affairs for review, and then hold a national conference on November 3 and 4, 2001, in Moncton.

The ambitious challenge of improving access to French-language services can be met only if all the stakeholders are committed to doing so. The Frenchspeaking communities must step up their efforts to encourage commitment within the communities. The government authorities and health institution administrators must view this challenge as a cost-effective investment in population health, rather than as an additional budget item. In addition, they must ensure that their decision-making processes take into account the unique needs of the French-speaking communities and that mechanisms or structures which effectively promote community empowerment are put in place, which will have positive repercussions on the entire Canadian population. It is within this framework that the Committee invites the federal government to work in cooperation with the provinces and the territories, as well as with the health institutions and the communities, to improve the accessibility of Frenchlanguage health services. Moreover, the comprehensive intervention strategy proposed by the Committee includes various initiatives that should be implemented in partnership with these stakeholders, in a spirit of co-operation.

Since the French-speaking communities have come to the realization that they must organize themselves to influence the offer of services, they will no longer passively accept receiving services in a language other than their own.

Sacred Heart Health Centre, McLennan, Alberta

Bibliography

1. Beaudin, Maurice. La francophonie par canadienne eu 1996, National Committee for Canadian Francophone Human Resources Development, Moncton, 1999.
2. Bowen, Sarah. Language Barriers in Access to Health Care, Ottawa, Health Canada, 2001, 141 p.
3. FCFA. Community Health Services in French: An Analysis of Four Existing Models in Francophone and Acadian Communities, Ottawa, the Fédération, 2000, 255 p.
4. FCFA. Grandir en français, utopie ou réalité?, Ottawa, the Fédération, 2000, 61 p.
5. Fédération des communautés francophones et Acadienne du Canada (FCFA). Improving Access to French-Language Health Services, Ottawa, The Fédération, 2001, 135 p.
6. Groupe Secor Inc. Calcus Louis Primaires, Montreal, le Groupe, 2001, 10 p.
7. Groupe Secor Inc.Calcus Louis Spécialisés, Montreal, le Groupe, 2001, 10 p.
8. Groupe Secor Inc. Coûts de mise eu place des modèls de prestetious de soius de santé-Une estimation basée sur la situation actuelle des communautés francophones et ecadienne, Montreal, le Groupe, 2001, 39 p.
9. Government Of Canada. Speech from the Throne to Open the First Session of the 37th Parliament of Canada, Ottawa, 2001.
10. Health Canada. Toward a Healthy Future: Second Report on the Health of Canadians, Ottawa, Health Canada, 1999, 230 p.
11. Infrastructure, Service Delivery and Technology Group. Accès à des services de santé en français pour les communautés francophones en situation minoritaire-Analyse complémentaire, Ottawa, Consultative Committee for French- Speaking Minority Communities, 2001, 51 p. Preliminary version.
12. National Health Training Centre (NHTC). Rapport sur les besoins de développement dans la formation post-secondaire de professionnels de la santé francophones, Ottawa, the Centre, 2001, 13 p. Preliminary version.
13. Networking Group. Pour des réseaux porteurs en santé, Ottawa, Consultative Committee for French-Speaking Minority Communities, 2001, 18 p. Preliminary version.
14. NHTC. Modalités de gouvernance-National Health Training Network, Ottawa, the Centre, 2001, 13 p. Preliminary version.
15. Programme de Recherche, d'éducation et de Développement en Santé Publique. Rapport sur la santé des francophones de l'Ontario, Sudbury, the Programme, 2000.
16. QARD, Demaude de service de santé, Ottawa, Health Canada, 2001, 4 p. Preliminary version of a table indicating an annual projection of the number of visits by francophones in the present health system. bibliography 36
17. Quantitive Analysis And Research Division (QARD) Compououson d'éfe moyen par province, Ottawa, Health Canada, 2001, 1 p. Preliminary version of a comparitive table indicating the average age of Francophones in each province and territory, and the average age of the whole population in these provinces and territories.
18. Réseau des services de santé en français de l'est de l'Ontario. Besoins et lacunes en matière de services de santé en français dans l'Est ontarien, the Réseau, September 1999, 68 p.
19. Robichaud, Jean-Bernard. Le système de services de santé, Vol. 2 in the series Objectif 2000, Vivre en santé en français au Nouveau-Brunswick, Édition d'Acadie, 1986.
20. Savoie, Donald J. Implementing Section 41 (Part VII), Official Languages Act, Ottawa, Health Canada, 2000, 20 p. Savoie Report.

Appendix A - List of CCFSMC members

Co-chairs

Hubert Gauthier -- St. Boniface General Hospital
Marie E. Fortier -- Health Canada

Co-secretaries

Paul-André Baril -- Fédération des communautés francophones et acadienne du Canada (FCFA)
Pierre LeBrun -- Health Canada

Representatives for the community sector

Georges Arès -- FCFA
Lucille Auffrey -- Canadian Nurses Association
Anne M. Leis -- University of Saskatoon
Dr Aurel Schofield -- Formation médicale francophone, New Brunswick
Jacques Schryburt -- Réseau des services de santé en français pour l'est de l'Ontario
Anna Veltri -- Collège du Savoir, Ontario
Dr Denis R.J. Vincent -- Private medical clinic, Edmonton

Provincial representatives

Edmond LaBossière -- Government of Manitoba
Lyne St-Pierre Ellis -- Government of New Brunswick
Denis Tardif -- Government of Alberta

Federal representatives

Gina Rallis -- Health Canada
Louise L. Trahan -- Canadian Heritage
Laurette Burch -- Health Canada
Marjolaine Guillemette -- Canadian Heritage (observer)
Cliff Halliwell -- Health Canada
David Fransen -- Health Canada
Murielle Brazeau -- Health Canada
Serge Lafond -- Health Canada

Appendix B - list of studied regions

Federal Representatives

Newfoundland	St. John's (including the Avalon Peninsula) West shore Labrador
Prince Edward Island	Queen's Prince Ouest East Prince
Nova Scotia	Clare Argyle Annapolis Valley Sydney Pomuet Halifax/Dartmouth Chéticamp Île Madame
New Brunswick	Beauséjour St. John Fredericton North-West Restigouche North-East Miramichi
Ontario (89 %)	Prescott/Russell Stormont/Dundas/Glengary Ottawa - Carleton Renfrew Toronto Hamilton/Wentworth Niagara Peel Simcoe Middlesex Essex/Kent Cochrane (Hearst/Kapuskasing) Cochrane (Timmins) Nipissing/Temiskaming Sudbury Algoma Thunder Bay Rest of the province*
Manitoba	Winnipeg South-East Central Entre-les-Lacs Parkland Marquette North-East
Saskatchewan (78 %)	Regina Saskatoon South Central Moose Mountain Parkland North East North Battleford Gabriel Springs Prince Albert Rest of the province*
Alberta (82 %)	Capital Calgary Lakeland Peace River Mistahia Rest of the province*
British Columbia (67 %)	Capital Vancouver Burnaby South Fraser Richmond South Okanagan Northern Interior Central Vancouver Coast Garibaldi Thompson Rest of the province*
Yukon (71 %)	Whitehorse Rest of the territory*
Nunavut (76 %)	Iqualuit Rest of the territory*

(%) Percentage Of Francophones Living In The Regions Studied.
* Region Which Were Not Part Of The Field Study.

Appendix C - list of preliminary recommendations made in October 2000

1. That during the implementation of the federal-provincial-territorial agreement on health of September 11, 2000, the mechanisms that contribute to the enhanced accessibility of health services for Frenchspeaking minority communities are included.
2. That Health Canada ensures the participation of French-speaking minority groups in Centres of Excellence for Children's Well-Being partnerships and that Health Canada collaborate with the Fédération des communautés francophones et acadienne (FCFA) to identify appropriate Francophone groups to serve as partners.
3. That Francophone experts who are members of French-speaking minority communities sit on the Centres of Excellence for Children's Well-Being Advisory Committee.
4. That the Canada Health Infostructure Partnerships Program (CHIPP) finances projects aimed at improving access to health services for Frenchspeaking minority communities.
5. That Health Canada ensures the presence of an adequate number of members of French-speaking minority communities on Canadian Institutes for Health Research Advisory Councils.
6. That Institutes for Health Research be commissioned to issue calls for tenders focussing on the health of French-speaking minority community members, particularly in the field of population health.
7. That Health Canada ensures the presence of an adequate number of members of French-speaking minority communities on the Rural Health Program Advisory Council.
8. That Health Canada collaborates with the FCFA to finance projects aimed at enabling French-speaking minority communities to improve their networking in the health sector.
9. That the co-chairs of the CCCFSM inform the Minister of the need to ensure that French-speaking minority communities are represented on advisory committees created by Health Canada.

Appendix D - List of preliminary recommendations made in April 2001

Short term:

1. Earmark for the funding of these initiatives a percentage of the national portion of the Primary Health Care Transition Fund. It is necessary to take into account the need of the French-speaking communities to catch up with respect to health services in their language and the fact that new services aimed at French-speaking populations benefit the Englishspeaking population living in the same area, since the professionals delivering the services are bilingual.
2. Give priority in the earmarking of the funds under the Interdepartmental Partnership with Official-Language Communities (IPOLC) agreement between Health Canada and Canadian Heritage to the networking initiative, since networking is the foundation of the strategy for improvement advocated by the Committee.

Medium and long term:

1. Implement an initiative aimed at supporting the organization of provincial/territorial networks as well as a national network.
2. Support the establishment of a true pan-Canadian consortium for the training of health professionals able to express themselves in French. A multi-institution consortium such as this would include French-language university institutions outside Quebec, including the National Health Training Centre, and Quebec institutions.
3. Support the establishment of infrastructures and intake facilities that will improve access to health services for French-speaking minority communities on the basis of demographic and geographic parameters and the services in place.
4. Ensure that the minority language communities have greater access to the Department's various programs or special funds (Population Health, InfoHealth, Research and so on) and that these programs and funds support the improvement of access to health services in French.
5. Plan special funding modules, such as a community action program targeting the French-speaking minority communities, in order to support networking, or funding via federal-provincial-territorial agreements to support the training of human resources or the operation of infrastructures or intake facilities for access to delivery of services in French.
6. Establish within the CIHR Institute of Population and Public Health a chair or other module for the special needs of the minority language communities.
7. Increase the awareness of other federal organizations (Statistics Canada, Canadian Institute for Health Information and so on) of the need to take linguistic aspects into account in their work.

Appendix E - Progressive Classification of Specialized Health Cares

Progressive Classification of the Specialized Health Service Delivery
Approaches based on the Communities' Needs and Capabilities

Progressive Classification of the Specialized Health Service Delivery

¹ Government of Canada, Speech from the Throne to Open the First Session of the 37th Parliament of Canada
² Ibid
³ Réseau des services de santé en français de l'est de l'Ontario. Besoins et lacunes en matière de services de santé en français dans l'Est ontarien, p. 17.
⁴ Ibid.
⁵ Jean-Bernard Robichaud, Le systéme des services de santé, Vol. 2 in the series Objectif/2000, Vivre en santé en français au Nouveau-Brunswick.
⁶FCFA, Pour un meilleur accès à des services de santé en français, p. 13 7
⁷Ibid.
⁸FCFA, op. cit., p. 28
⁹Ibid., p. 37
¹⁰Webster's Ninth New Collegiate Dictionary, 1991, p. 49.