2003 First Ministers' Accord on Health Care Renewal^{Footnote 1}

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In September 2000, First Ministers agreed on a vision, principles and action plan for health system renewal. Building from this agreement, all governments have taken measures to improve the quality, accessibility and sustainability of our public health care system and all have implemented important reforms. Federal and provincial/territorial governments have also commissioned a number of task forces and studies that reflect the views of Canadians. These studies reflect a great convergence on the value of our publicly funded health system, the need for reform, and on the priorities for reform: particularly primary health care, home care, catastrophic drug coverage, access to diagnostic/medical equipment and information technology and an electronic health record.

Canadians want a sustainable health care system that provides timely access to quality health services. They recognize that reform is essential, and they support new public investments targeted to achieve this goal.

This Accord sets out an action plan for reform that reflects a renewed commitment by governments to work in partnership with each other, with providers, and with Canadians in shaping the future of our public health care system.

A Commitment to Canadians

Canadian values are reflected in the five principles of public health insurance: Universality, Accessibility, Portability, Comprehensiveness and Public Administration. First Ministers reaffirm their commitment to these principles. They also commit to enhancing the transparency and accountability of our health care system while ensuring that health care remains affordable.

Drawing from this foundation, First Ministers view this Accord as a covenant which will help to ensure that:

• all Canadians have timely access to health services on the basis of need, not ability to pay, regardless of where they live or move in Canada;
• the health care services available to Canadians are of high quality, effective, patient-centred and safe; and
• our health care system is sustainable and affordable and will be here for Canadians and their children in the future.

First Ministers believe that the initiatives set out in this Accord will result in real and lasting change. The ultimate purpose of this Accord is to ensure that Canadians:

• have access to a health care provider 24 hours a day, 7 days a week;
• have timely access to diagnostic procedures and treatments;
• do not have to repeat their health histories or undergo the same tests for every provider they see;
• have access to quality home and community care services;
• have access to the drugs they need without undue financial hardship;
• are able to access quality care no matter where they live; and
• see their health care system as efficient, responsive and adapting to their changing needs, and those of their families and communities now, and in the future.

All governments have made significant investments in health care since the First Ministers' agreement of September 2000. First Ministers agree that public health care in Canada requires more money, but that money alone will not fix the system. While all jurisdictions are making progress on health reform, First Ministers agree that significant new investments must address immediate cost pressures and the reforms necessary to achieve timely access to quality care in a sustainable manner. The federal government will continue to work with territorial governments to address their unique challenges.

A Plan for Change: A new Health Reform Fund for Primary Health Care, Home Care and Catastrophic Drug Coverage

First Ministers agree that additional investments in primary health care, home care and catastrophic drug coverage are needed for a long-term sustainable public health care system in Canada. The federal government will create a 5 year Health Reform Fund which will transfer resources to the provinces and territories to address these three priorities. Recognizing that provinces and territories are at differing stages of reforms in these areas, the Fund will provide the provinces and territories the necessary flexibility to achieve the objectives set out below. Premiers and Territorial Leaders agree to use the Health Reform Fund to achieve these objectives. Therefore, these funds to be transferred to the provinces and territories will be available for any of the programs described within the Health Reform Fund, at their discretion. Achievement of the objectives of the Health Reform Fund by a province or territory will allow use of any residual fiscal resources in the Fund for other priority areas of their own health system.

The Government of Canada will establish a new long-term Canada Health Transfer (CHT) by March 31, 2004. It will include the portion of the current CHST (both cash and tax points) corresponding to the current proportion of health expenditures in provincial

social spending supported by this federal transfer. In establishing the CHT, the federal government will ensure predictable annual increases in health transfers.

Subject to a review of progress toward achieving the agreed-upon reforms and following a First Ministers' Meeting, by March 31, 2008, the federal government will ensure that the level of funding provided through the Health Reform Fund is also integrated into the CHT.

Primary Health Care: Ensuring Access to the Appropriate Health Provider When Needed

The key to efficient, timely, quality care is primary health care reform. First Ministers agree that the core building blocks of an effective primary health care system are improved continuity and coordination of care, early detection and action, better information on needs and outcomes, and new and stronger incentives to ensure that new approaches to care are swiftly adopted and here to stay.

First Ministers agree that the ultimate goal of primary health care reform is to provide all Canadians, wherever they live, with access to an appropriate health care provider, 24 hours a day, 7 days a week. Towards this goal, First Ministers agree to immediately accelerate primary health care initiatives and to make significant annual progress so that citizens routinely receive needed care from multi-disciplinary primary health care organizations or teams. First Ministers agree to the goal of ensuring that at least 50% of their residents have access to an appropriate health care provider, 24 hours a day, 7 days a week, as soon as possible and that this target be fully met within 8 years. First Ministers agree that each jurisdiction will publicly set out its own multi-year targets for verifiable progress towards achieving this objective.

Home Care for Canadians

Improving access to a basket of services in the home and community will improve the quality of life of many Canadians by allowing them to stay in their home or recover at home. First Ministers direct Health Ministers to determine by September 30, 2003, the minimum services to be provided. Such services provided in the home can be more appropriate and less expensive than acute hospital care. To this end, First Ministers agree to provide first dollar coverage for this basket of services for short-term acute home care, including acute community mental health, and end-of-life care. First Ministers agree that access to these services will be based on assessed need and that, by 2006, available services could include nursing/professional services, pharmaceuticals and medical equipment/supplies, support for essential personal care needs, and assessment of client needs and case management. The Government of Canada will complement these efforts with a compassionate care benefit through the Employment Insurance Program and job protection through the Canada Labour Code, for those who need to temporarily leave their job to care for a gravely ill or dying child, parent or spouse.

Catastrophic Drug Coverage and Pharmaceuticals Management

First Ministers agree that no Canadian should suffer undue financial hardship for needed drug therapy. Accordingly, as an integral component of these reforms, First Ministers will take measures, by the end of 2005/06, to ensure that Canadians, wherever they live, have reasonable access to catastrophic drug coverage.

As a priority, First Ministers agree to further collaborate to promote optimal drug use, best practices in drug prescription and better manage the costs of all drugs including generic drugs, to ensure that drugs are safe, effective and accessible in a timely and cost-effective fashion.

Reporting

First Ministers agree to prepare an annual public report to their citizens on each of the above three areas commencing in 2004. They further agree to use comparable indicators and to develop the necessary data infrastructure for these reports. This reporting will inform Canadians on progress achieved and key outcomes. It will also inform Canadians on current programs and expenditures, providing a baseline against which new investments can be tracked, as well as on service levels and outcomes.

A Plan for Change: Diagnostic/Medical Equipment Fund

Enhancing the availability of publicly-funded diagnostic care and treatment services is critical to reducing waiting times and ensuring the quality of our health care system. To this end, First Ministers agree to make significant new investments, including support for specialized staff training and equipment, which improve access to publicly funded diagnostic services. The Government of Canada will establish a Diagnostic/Medical Equipment Fund for that purpose.

Commencing in 2004, First Ministers agree to report to their citizens on an annual basis on enhancements to diagnostic and medical equipment and services, using comparable indicators, and to develop the necessary data infrastructure for these reports. This reporting will inform Canadians on progress achieved and key outcomes. It will also inform Canadians on current programs and expenditures, providing a baseline against which new investments can be tracked, as well as on service levels and outcomes.

A Plan for Change: Information Technology and an Electronic Health Record

Improving the accessibility and quality of information is critical to quality care, patient safety and sustainability, particularly for Canadians who live in rural and remote areas. Better use of information technology can also result in better utilization of resources. First Ministers agree to place priority on the implementation of electronic health records and the further development of telehealth applications which are critical to care in rural and remote areas. The Government of Canada will provide additional support for Canada Health Infoway to achieve this objective. First Ministers are also committed to the appropriate protection of personal information in building a national system of electronic health records.

Canada Health Infoway will report to the Canadian public and to the members of Infoway, who are Deputy Ministers of Health of federal/provincial/territorial governments, on an annual basis on its progress in implementing these initiatives. This reporting will inform Canadians on current programs, investment expenditures and milestones.

Additional Reform Initiatives

The adoption of innovations and the sharing of best practices by health care providers and managers is critical to making health care more efficient and improving its quality. First Ministers commit to accelerate collaborative work on priority issues with respect to patient safety, health human resources, technology assessment, innovation and research, and healthy living. The federal government is committed to providing funding in support of this work.

Building from this, First Ministers direct Health Ministers to work on the following:

Patient Safety

The implementation of a national strategy for improving patient safety is critical. Health Ministers will take leadership in implementing the recommendations of the National Steering Committee on Patient Safety.

Health Human Resources

Appropriate planning and management of health human resources is key to ensuring that Canadians have access to the health providers they need, now and in the future. Collaborative strategies are to be undertaken to strengthen the evidence base for national planning, promote inter-disciplinary provider education, improve recruitment and retention, and ensure the supply of needed health providers (including nurse practitioners, pharmacists and diagnostic technologists).

Technology Assessment

Managing new technologies and treatments is critical to ensuring that our health system remains relevant to the evolving needs of Canadians. Health Ministers are directed to develop, by September 2004, a comprehensive strategy for technology assessment which assesses the impact of new technology and provides advice on how to maximize its effective utilization in the future.

Innovation and Research

Applied research and knowledge transfer are essential to improving access and the quality of care. The work of academic health centres is vital in developing new approaches for the collection of information and evidence needed to improve care.

Healthy Canadians

An effective health system requires a balance between individual responsibility for personal health and our collective responsibility for the health system. Coordinated approaches are necessary to deal with the issue of obesity, promote physical fitness and improve public and environmental health. First Ministers direct Health Ministers to continue their work on healthy living strategies and other initiatives to reduce disparities in health status. First Ministers further recognize that immunization is a key intervention for disease prevention. They direct Health Ministers to pursue a National Immunization Strategy.

Aboriginal Health

First Ministers recognize that addressing the serious challenges that face the health of Aboriginal Canadians will require dedicated effort. To this end, the federal government is committed to enhancing its funding and working collaboratively with other governments and Aboriginal peoples to meet the objectives set out in this Accord including the priorities established in the Health Reform Fund. Governments will work together to address the gap in health status between Aboriginal and non-Aboriginal Canadians through better integration of health services.

First Ministers direct Health Ministers to consult with Aboriginal peoples on the development of a comparable Aboriginal Health Reporting Framework. They further agree to consult with Aboriginal peoples in this effort, to use comparable indicators, and to develop the necessary data infrastructure. This reporting will inform Canadians on progress achieved and key outcomes. It will also inform Canadians on current programs and expenditures, providing a baseline against which new investments can be tracked, as well as on service levels and outcomes.

Reporting to Canadians on Change

First Ministers agree that Canadians are entitled to better and more fully comparable information on the timeliness and quality of health care services. Enhanced accountability to Canadians and improved performance reporting are essential to reassuring Canadians that reforms are occurring. To this end, First Ministers agree that:

• each jurisdiction will report to its constituents on its use of all health care dollars spent on an annual basis;
• each jurisdiction will continue to provide comprehensive and regular public reporting on the health programs and services it delivers as well as on health system performance, health outcomes and health status;
• these reports will include the indicators set out in the September 2000 communique as well as additional comparable indicators, to be developed by Health Ministers, on the themes of quality, access, system efficiency and effectiveness based on Annex A of this Accord; and
• jurisdictions will develop the necessary data infrastructure and collect the data needed for quality reporting.

This will enable the development of nationally comparable information for Canadians on the themes of access, quality, system efficiency and effectiveness and on reform priorities and objectives set out in this Accord.

First Ministers recognize that Canadians want to be part of the implementation of this Accord. Accordingly, they agree to establish a Health Council to monitor and make annual public reports on the implementation of the Accord, particularly its accountability and transparency provisions. The Health Council will publicly report through federal/provincial/territorial Ministers of Health and will include representatives of both orders of government, experts and the public. To fulfill its mandate, the Council will draw upon consultations and relevant reports, including governments' reports, the work of the Federal/Provincial/Territorial Advisory Committee on Governance and Accountability and the Canadian Institute for Health Information (CIHI). Health Ministers will establish the Council within three months. Quebec's Council on Health and Welfare, with a new mandate, will collaborate with the Health Council.

Annex A to Accord - Performance Indicators

First Ministers direct Health Ministers to develop further indicators to supplement the work undertaken in follow-up to the September 2000 Communique. This work is to be completed by September 2003, following review by experts and stakeholders, to ensure these new indicators measure progress on achieving the reforms set out in this Accord and meet the following objectives:

• Timely Access: the measurement of access to essential services across the country as well as waiting times;
• Quality: the measurement of quality of health care services across the country, including patient safety, patient satisfaction and health outcomes;
• Sustainability: including measurements of the state of health human resources, equipment, information systems and value for money from the system; and
• Health Status and Wellness.

Ministers are to consider the following:

Timely Access Indicators

Access to health care providers/services

• % of population having a regular family doctor (FMM 2000)
• % of doctors accepting new patients
• number of multi-disciplinary primary health care organizations or teams by region (rural/urban)
• % of population having access to 24/7 primary care provider (e.g, nurse practitioner, doctor)/telehealth/online health information
• % of population routinely receiving needed care from a multi-disciplinary primary health care organization or team
• % of population with public coverage of core set of home care services

Wait Times/Volume measures for

• radiation therapy for breast and prostate cancer, cardiac bypass surgery, hip and knee replacement surgery (FMM 2000)
• referral to specialists for cancers (lung, prostate, breast, colo-rectal), heart and stroke
• emergency rooms from entry to discharge (seasonally adjusted)
• diagnostic tests (MRI, CT)
• from referral to provision of first home care service
• waiting period before being eligible for public coverage of home care services in another jurisdiction
• proportion of services/facilities linked to a centralized (provincial/regional) wait list management system for selected cancers and surgeries, referral to specialists, emergency rooms and diagnostic tests (all of the above wait time indicators)

Catastrophic Drug Coverage

• to be developed

Quality Indicators

Patient Safety

• reported medical error/events (e.g., disease surveillance, adverse drug reactions) - to be determined by proposed Institute on Patient Safety

Patient Satisfaction (FMM 2000)

• overall health care services
• hospital care
• physician care
• community-based health care
• telehealth/online information

Health Outcomes

• readmissions for selected conditions
  • AMI, pneumonia (FMM 2000)
  • congestive heart failure, GI haemorrhage
• mortality rate for cancers (FMM 2000)
• survival rate for cancers (FMM 2000)

Sustainability (Efficiency and effectiveness) Indicators

Health Human Resources

• age distribution of practicing providers by area of specialty
• number of providers (by specialty) leaving/entering the system each year
• a 10-year rolling forecast of providers expected to enter system (trained in Canada, incoming from other countries)

Equipment

• number and types of equipment installed
• number of diagnostic professionals to operate equipment
• volume flow/wait times for MRI, CT (covered under access indicators)

Information Systems

• progress on building information systems
• degree of standardization of information collected and shared for evidence-based decision-making
• degree of technology utilization based on evidence

Value for Money - qualitative indicators primarily

• annual health reports on plans and priorities reported by every jurisdiction
• expenditures linked to reform areas (link inputs to outputs)
• lessons learned and best practices shared within and between provinces/territories
• comparisons of productivity measures

Health Status and Wellness

• % of Canadians engaged in physical activities
• % of Canadians with recommended Body Mass Index (BMI)
• Potential years of life lost (PYLL)
• Disability-Free Life Expectancy (DFLE)
• Cost of Illness