Canada

The health care system has been shown to be the number one symbol of Canadian identity; Canadians consider health care a fundamental right: the solid determination to maintain a publicly funded health care system is a reflection of its significant importance. From a health perspective, Canada has undergone significant change in the 1990s; both positive and negative. Positive developments include the higher profile of a health determinants approach and the recognition that expanded intersectoral involvement in health policy development is essential to this approach be successful; the recognition that gender is a determinant of health and therefore health system should be more responsive to the needs of women; and federal iniciatives with respect to Aboriginal self-government, specifically in regards to health care: health programs operated by Aboriginal peoples culturally tailored to meet the specific needs of their communities. By contrast, the pressure for increased fiscal restraint and privatization, and the resulting call for market solutions, have been viewed as negative influences. Cutting or containning government expenditure does not constitute health system renewal; reduction in government expenditure invites growth in private spending, which lacks the expenditure control and discipline of public monopolies. In fact, the private share of Canadian health spending is the fastest growing, conceivably leading to inequities in care. However, the federal health strategy aims to preserve the principles of the Canada Health Act, restrict total spending -public and private-, while improving the balance between prevention and treatment. Given the current fiscal realities, some steps toward health system renewal have been taken: there have been major changes at the level of health system governance, evidenced by a general trend towards decentralization and an emphasis on priority setting at the local level. Evidence-based decision making has been clearly recognized for its importance, attemps are under way to develop a model of best practices, and there is a recognition that the present model of physician remuneration merits reconsideration. Designed to impact the health of the entire population, in 1994 a Population Health Framework was implemented which -differing from traditional medical and health care thinking- it goes beyond risks and clinical factors related to particular diseases, addressing the entire range of factors that determine health. Canadians are confronted by two challenges: to provide cost-effective care through a publicly funded health care system, and to avoid fostering a situation where services are allocated on the basis of ability to pay rather than need.

2.1 Economic trends. The Canadian economy has expanded at a moderate pace since 1992; economic growth peaked at 4.1% in 1994, but slowed thereafter. An increase in real net exports was the main impetus for growth over this period, but recent domestic spending has also shown sign of strength. The unemployment rate has fallen from 11.3% in 1992 to 9.9% in the fourth quarter of 1996, although strong growth in private sector has been tempered by declines in public sector. Since early 1990s, the federal and provincial/territorial governments have actively sought to restore Canada =s fiscal health and to sustain economic growth: from 1992 to 1995, federal and provincial governments have reduced their budgetary deficits by more than 30% (from 5.9% to 3.7% of GDP, and from 3.6% to 1.5%), particularly through cuts in programs expenditures (from 17.8% of GDP to 14.4%, and from 20% to 17.5%). As a result of program spending restraint and lower public debt charges, the operating balance of the total government sector shifted form a deficit to a surplus position since 1994-95. Publicly financed health expenditures declined from 7.5% of GDP in 1991 to 6.9% in 1994; public sector health expenditures went from 74.6% of total health expenditures in 1991 to 71.8% in 1994. The decreases in health spending as a percentage of GDP indicated a levelling off, but also a decline of the health spending/GDP ratio now that the economy has recovered from a period of low economic growth.

2.2 Demographic trends. Birth and death rates are low and life expectancy high. Although fertility experienced a modest upsurge in the late 1980s, of late it has steadily declined. As a result, the number of children under the age of 14 is decreasing. Women are delaying childbirth, the average age of a mother at first birth being 28.8 years; women aged 30 and over accounted for 42.6% of all births in 1995. At the same time, the number of women in childbearing years continues to shrink, leading to different requirements in health services. As a whole, the Canadian population is aging. In 1995, persons over 65 years accounted for 11.7% of the population (8% in 1961). Health services are disporportionately consumed by the elderly, accounting for an estimated 38.7% of total health expenditures. Canada =s population is highly urbanized: from 1991 to 1995, rural population declined from 23 to slightly less than 20%; large urban centres account for just over 60% of the population. Not surprisingly, physicians and health service organization are concentrated in urban places. Some provincial governments are reviewing uneven patterns of care distribution, with a view toward rectifiying the urban-rural disparities in regards to accesibility of health care services and availability of specialized treatment. Immigration has increased the ethnic and cultural makeup of the Canadian population. In recent years, the legislation governing who can be considered an Aboriginal person has changed, resulting in the reinstatement of a large number of women and children who were formerly considered not to have Aboriginal status. In addition, there has been a net migration from urban areas back to (predominantly rural) Aboriginal reserves in recent years.

2.3 Social trends. In several areas, there have been social improvements that have influenced the health of Canadians. Educational levels continue to rise. More people have post secondary education and university degrees, and fewer have less than a grade 9 education. Furthermore, fewer persons over the age of 65 live in poverty: the poverty rate dropped from one-third of seniors in 1980 to fewer than one-fifth in 1994. Nevertheless, the gap between women and men has not altered appreciably: older women remain more likely to have lower incomes than older men. Child poverty rates have remained at roughly the same level over the past ten years: one child in every five- lived in a low income family. Additionally, income inequality is growing: as more wealth is acquired by fewer people, the low income population grows, and the size of the middle class shrinks.Thus far, the social safety net -through income tax, social assistance, unemployment insurance, and other transfer programs- has been able to offset the trend toward inequality in earnings. Nevertheless, building on milestones such as the Lalonde Report (1976), Achieving Health for All (1984), Strategies for Population Health (1994), and the Report on the Health of Canadians (1996), federal, provincial, and territorial governments have endorsed a population health approach and are developing multi-sectoral actions such as the National Forum on Health, the Child Development Initiative, the Strengthening Canada =s Health Intelligence Network, Tobacco Demand Reduction Strategy, St. Lawrence Vision 2000 Knowledge Development Fund, Family Violence Prevention, Aboriginal Head Start, and Strategic Research Program and Transfer of Indian Services to First Nation, among others.

2.4 Food supply and nutritional status. In 1992, Canada developed a national plan on nutrition: Nutrition for Health: An Agenda for Action, which identifies four strategic directions -to reinforce healthy eating practices, support nutritionally vulnerable populations, continue to enhance the availability of foods that support healthy eating, and support nutrition research- and high priority actions where resource allocation will have the greatest impact on health. The Agenda acknowledges that Adisparities in nutritional well-being are evident in Canada @, that Anutritional vulnerability related to poverty is more prevalent within subgroups within the population @, and that "an increasing number of Canadians are turning to food banks in an attempt to meet food needs. A variety of smaller scale, community initiatives such as collective kitchens, community gardens, food buying clubs, school-based breakfast and lunch clubs have emerged to address the problem". Obesity is also a growing problem in the population. By far, the most significant change since 1991 is the increasingly rapid transfer of health resources and responsibilities to Aboriginal communities to allow them to make the most appropriate health decisions; second, efforts to strengthen nutrition knowledge and skills through programs such as the Canada Prenatal Nutrition Program, facilitate health for all; third, securing of the Air Stage Subsidy Program funds in order to subsidize the shipment of nutritious foods by aircraft to remote communities has also been important in fostering healthy eating practices.

2.5 Lifestyle. The changing social, physical and health system environments influence lifestyles of Canadians and impact on their nutritional health. Increased physical activity is a positive trend: in 1995, one in ten Canadians are physically active every day and seven in ten are active at least every other day; however, Canada is not yet an active nation: 60% of Canadians have not yet integrated physical activity into their daily lives, as participation levels have not increased. New opportunities and challenges with reproductive health have recently come to the forefront: Health Canada is currently working on elements of a comprehensive approach towards reproductive and genetic technologies such as regulation for sperm donation, and sexual and reproductive framework which will also address the prevention of infertility. The teen pregnancy rate has increased over the past ten years after several years of decline in the mid to late 1970s. Sexual activity in Canada starts at an early age; teens are aware of various methods of birth control, being the condom and the oral contraceptive the most used. The abortion rate for younger teens 11-17 has remained about the same from 1974 to 1994 at the rate of about 11 per 1000 young women; there has been a rise among 18 to 19 year-olds from 16 to 22 per 1000 in the same period; the age group with the largest increase was the 20 to 24 year-olds at 13 to 21 per 1000. Specific actions taken since 1992 to ensure lifestyles have a positive influence on health and health status include Child Development Initiative, to address such areas as injury prevention and healthy babies; Canada Prenatal Nutrition Program, to promote healthy pregnancies and healthy babies among high-risk pregnant women; Building Healthy Communities, to address solvent abuse, mental health and continuing care; and Tobacco Demand Reduction Strategy, Family Violence Initiative, and National Native Alcohol and Drug Addictions Programs, to support community development of strategies, services and activities. These actions include building partnership and promoting equity through the creation of supportive environments.

3. Health and environment

3.1 General protection of the environment. The general trend in environmental quality has been a gradual improvement; for instance, dietary intake of chemical contaminants has decreased, as well as the loading of toxic chemicals in major rivers and watershed basins; also, there is an abatement in acid precipitation. However, in large urban areas air pollution continues to be a concern and sustainable development is a challenge. The Canadian Environmental Assessment Act, proclaimed 1995, requires federal departments and agencies to assess the environmental implications of all their projects; the Canadian Environmental Protection Act aims to protect human health and the environment by reducing or eliminating toxic substances from the environment. Prevention of food borne disease is an important issue: 2.2 million cases and an estimated economic lost of $1.3 billion annually. Since 1996, the federal government separated responsibility for food inspection activities from food safety iniciatives; Health Canada directs risk assessment, research, and standard-setting in food safety, as well as to evaluate the safety of related industry submissions. Although a national plan for the control of enteric disease has been proposed, it has yet to be established. In regard to the housing of First Nations/Inuit peoples, the federal policy is aimed at improving living conditions on reserve by addressing the basic shelter needs of residents; the goal is to establish and maintain a level of family accommodation that meets national building code standards.

3.2 Water supply and sanitation. In Canada, 99% of population has safe water, and 95% has satisfactory sewage facilities (95% and 90% for Canada's First Nations/Inuit peoples). In recent years public awareness of water quality issues has increased and led to positive changes influencing the health of the population; accordingly, companies have taken steps to improve the effluent quality of both drinking water and sewage treatment. Municipalities are confronted with an aging underground infrastructure; thus, improvements are necessary. However, to merely maintain the current infrastructure will cost governments an estimated $10 billion over the next four years. In order to renew the strategy for health for all, the federal and provincial/territorial governments are proceeding with sustainable development initiatives, water conservation strategies, and the formulation of guidelines. The federal government has also introduced new legislation concerning drinking water in the form of a Drinking Water Materials Safety Act.

4. Health resources

4.1 Human resources for health. Strategies and inititatives are under way in every province and territory to improve the major components of the health system. Although the extent and type of reform differ between provincial/territorial jurisdictions, all share common objectives: an increased focus on innovative and integrated community-based services and overall cost control, including significant down-sizing and rationalization of administrative, institutional-based diagnostic services. Defined needs for health human resources are being reviewed; current challenges include identifying the optimum number and mix of health human resources in a reformed health system, and improving mechanisms for information sharing. Issues such as skill substitution, complementary roles and a change in the method of remuneration, particularly for physicians who are currently paid on a fee-for-service basis, are being addressed. Since 1992, a National Strategy for Physician Resource Management is being implemented through an Action Plan which has four national policy directions: reducing Canadian medical school entry class size by 10%; reducing national postgraduate medical training positions by 10%; reducing the recruitment of visa trainee graduates of foreign medical schools into Canada for postgraduate medical training; and, supporting the development and implementation of national clinical guidelines, with an emphasis on health outcome research, that can serve as a basis for the funding and provision of both ambulatory and institutional medical services. Training to meet rural population health needs is one of the priority issues that has been identified; also, there is an interest in increasing the output of generalist-specialists and decreasing the proliferation of subespecialist physicians. Utilization of community-based health workers is generally increasing, especially in the number of registered nurses, licensed practical nurses/registered nursing assistants, nurses' aides and home support workers.

4.2 Financial resources for health. Health expenditures in Canada are financed from public and private funds. The publicly funded portion of health care is financed primarily through taxation, both provincial and federal personal and corporate income taxes. In addresing the issues of health cost containment and efficiency, Canada has not moved in the direction of managed competition or the creation of internal markets, but rather focuses on quality assurance and the role of provinces in reviewing their lists of services provided, assuring that the provinces are financing high quality services which are directed toward health gains. As a result, Canada has been successful in its efforts to contain health care expenditures: in the mid-1990s, health expenditures have levelled off and are expected to decline in the future. The annual rate of growth of national health expenditure declined to an estimated 1.0% for 1994, compared to 2.5% for 1993, down significantly from the annual rate of 8.6% experienced at the beginning of the 1990s. On the other hand, national health expenditures increased to approximately $72.5 billion, or $ 2,478 per person; this is up about $700 million from the previous year, and accounted for just 9.7% of GDP in 1994, down from the 1992 and 1993 peak level of 10.1% of GDP; growth in the economy (GDP) for 1994 was 5.2% compared to 3.3% for 1993. The public share of this total health expenditure had declined to 71.8% (by 4.6% from 1975), while the private share had increased to 28.2%. Given their primary role in health services delivery, provincial/territorial governments accounted for 66.3% of the total health expenditures in 1994; federal government health transfers to these jurisdictions represented 21.9% of the total provincial/territorial spending. While the need for increased efficiency and cost-containment is recognized, there is also a growing understanding of the need to modify the future population's health requirements by fostering greater awareness of the actual impact of health care.

4.3 Essential drugs and other supplies. In Canada, the essential drug list is a short list of drugs which should be available to all persons within the country; citizens have access to these essential drugs. In order to renew the strategy for health for all, Canada is considering efforts at increasing efficiency in the drug review process which enhances the health of Canadians by making available new drugs in a timely manner.

5. Development of the health system

5.1 Health policies and strategies. Canada truly believes intersectoral collaboration is the key to developing a common definition and understanding of the key priorities for action. Effective health strategies are also built on evidence based decision making. In recognition of the importance of developing the evidentiary knowledge base, the federal government launched the Health Services Research Foundation, and will commit $65 million dollars over 5 years. The foundation is independent of government, its mandate being to support peer-reviewed research and disseminate results. To combat the serious lack of research on women's health, the federal government also established the Centres of Excellence for Women's Health. Charged with responsibility for the generation and dissemination of knowledge, each of the five centres will recieve $2 million over a 6 year period. Canada recognizes that healthy children grow into healthy and productive adults. Therefore, a comprehensive intersectoral population health iniciative is being developed, focusing in particular on children. By having several federal departments and agencies work in concert to examine determinants such as income, social support, education, the environment, and early chilhood development, the cross-sectoral iniciative demands of investing in children. Moreover, it reflects the linkage between social and economic policy.

5.2 Intersectoral cooperation. Health Canada recognizes that cooperation across many sectors, along with support from the general public, is necessary to not only maintain and improve the health of Canadians, but to reduce inequalities in health status. Consequently, over the past several years, intersectoral cooperation to achieve established health goals has been strongly evident in Canada. There has been a continued increase in collaboration on joint federal health projects, and initiatives with provincial and territorial governments, national and international health organizations, community organizations, and the private sector. Some examples include: Tobacco Demand Reduction Strategy, Canada's Drug Strategy, Action Plan on Health and the Environment, Family Violence Initiative, Canada's Seniors Initiative, National Action Plan for Nutrition, and National AIDS Strategy. In practice, intersectoral cooperation is difficult to achieve. A case of point is the Child Development Initiative (CDI) evaluation, completed in 1996. The evaluation indicates that a substantial amount of time and effort was required to sustain partnership, in particular at the federal/provincial level. A second constraint is the fact that intersectoral cooperation is a long-term, emergent process, and therefore requires sustained commitment on the part of cooperants. A third barrier is the fear of and resistance to changes in approaches and practices, particularly within a public sector environment that is characterized by fiscal restraint and cutbacks. And a fourth impediment may be the nature of a health issue itself; v.g., consensus as to a singular approach to combat the HIV/AIDS epidemic is difficult to achieve. Canada accepts that health is more than health care, and that the health status of citizens is determined by a variety of factors; so intersectoral cooperation and broad based public support are essential for the successful implementation of population health strategies: many sectors must work in partnership with all levels of government to renew the strategy for health for all.

5.3 Organization of the health system. Canada has a predominantly publicly financed health care system that is best described as an interlocking set of ten provincial and two territorial health insurance schemes. This has made for an already highly decentralized system. However, all provincial/territorial hospital and medical care insurance schemes must adhere to national principles set at the federal level in the Canada Health Act. This structure results from the constitutional assignment of jurisdiction over most aspects of health care to provincial governments. The health care insurance program entitles residents to coverage, without financial charges, for medically necessary hospital and medical care. In terms of primary health care delivery, general practitioners (GPs) and family physicians provide the majority of these services; generally they represent a client's initial contact with the formal health care system and control access to most specialist, many allied providers, admissions to hospitals, diagnostic testing and prescription drug therapy. Patients are free to choose their own physicians. Most GPs and doctors enjoy a substantial level of autonomy. Specialized ambulatory physician care is provided on much the same basis as general practitioner care. A second access point for the health care system in through the hospital emergency room. A number of allied health care personnel, v.g., pharmacists, dentists, and nurses, are also involved in the delivery of primary health care; the reintroduction of nurse practitioners and midwifes may signal a larger role for allied health personnel in the provision of primary health care, particularly in remote areas. Canadian provinces, with only one exception, have adopted one form or another of decentralization or regionalization as part of recent reform initiatives. Four provinces have adopted two-tier deconcentration models, with interlocking regional authorities and local or community health boards; four have introduced single-tier deconcentration models (one has regionalized the institutional sector), while one province has used a single-tier devolution model. Although the effect has been to increase the privatization of some services, the impact of these models of decentralization has been negligible: most privatization that has ocurred is at the institutional level, with hospitals contracting out non-medical support services such as laundry, meal preparation or inventory control. Despite the widespread acceptance of decentralization, three health sectors -primary health care, pharmacare, and physician services- remain under direct provincial control in all but one province. Governance of the Health Authorities on Board has also taken on varied approaches: a few provinces are proposing or have introduced elected boards, while others have opted to continue to rely on appointments from the health sector and general population. some provinces, however, have excluded providers from representation on regional or local boards. The introduction of changes in the organizational structure of provincial and First Nations/Inuit health care system have not been without challenges; various stakeholders have expressed concerns about both the implementation and effect of this reform process. As the Canadians and First Nations/Inuit population continues to grow and the concomitant cost of providing health services increases, it remains to be seen whether the trend toward decentralization will generate improved health outcomes.

5.4 Health information system. Since the delivery of health care is provincially and territorially regulated, each province and territory has a separate health information system to serve its particular purposes. Therefore, the national health information system per se is actually a complex assortment of components, operating in different places and at different levels, often quite independently of one another. However, over the years, federal government departments and other national organizations, have, through agreements with the provinces and territories, instituted many national health information systems, maintained according to national standards. In 1990, the first Task Force on Health Information recommended the formation of a Canadian Institute for Health Information (CIHI), that was officially incorporated in 1993 as an independent, not-for-profit organization to coordinate the development and maintenance of a comprehensive and integrated health information system for Canada. The Task Force also recommended the development of a longitudinal National Population Health Survey (NPHS), the creation of linkage methodologies to produce person-oriented information on health outcomes and the recognition, in provincial health care reform initiatives, of the need for more integrated health information systems. Despite these actions, outstanding data quality issues remain. In Canada, quantitative data on health of individuals is presently derived from one of two sources: first is the self-reporting mechanism, principally the household survey; the second is contact reporting by the administrative systems overseeing the delivery of and payment for health products and services. Unfortunately, neither self-reporting nor contact reporting adequately meets Canada's health information needs. Partnership represent an attempt to resolve these imbalances. The three main organizations responsible for suplying health information -CIHI, the Laboratory Centre for Disease Control (LCDC) and Statistics Canada (STC)- to those whose responsibility is the renewal of health for all, are national in scope and will remain as such in the foreseeable future.

5.5 Community action. Community action continues to be an important element of individual and community health. Through such mechanisms as the National Forum on Health, the federal and provincial governments have sought to foster individual and community debates on health system changes. The federal government is a major supporter of community action. Nevertheless, it must contend with resource pressures. The changes and constraints faced by community action stem from two important challenges: the pressure on private and public resources devoted to community action and the restructuring of health models: community action in the future is likely to embody several aspects of a population health approach.

5.6 Health research and technology. During 1996, developments occurred in the area of health research in Canada, most importantly being the endowment of $65 million over five years specifically in support of health services research, and the subsequent creation of the Canadian Health Services Research Foundation to administer the endowment and to raise additional funds. Several activities are on-going to improve the uptake of technology for the development of products which will contribute to health. The Medical Research Council of Canada (MRC) has pursued several private and publicly financed endeavours to facilitate technology transfer. The MRC also administers the health component of the Networks of Centres of Excellence program, that encourages technological transfer by linking researchers and the bussiness community. The main impediment to these efforts is the lack of financial resources. The low overall level of private sector investment in research and development in Canada relative to other G7 nations is also cause of concern. Encouraging private sector funding on health research is therefore a priority for government.

6. Health services

6.1 Health education and promotion. Health promotion programs in Canada, as elsewhere, have become increasingly comprehensive in nature, combining a variety of approaches including health education, social marketing, support for community action, and policy and legislative changes. Together, these approaches have been targeted at improving peoples's health behaviours as well as environments in which they live and work. Over the past few years, as discussed earlier, Health Canada has introduced several iniciatives that are strategic as well as comprehensive; while it is difficult to ascribe changes in health status directly to these interventions, it appears that they are having an impact on the health knowledge and behaviour of Canadians. For example, in 1990, nearly 10 million Canadians reported improvements in their personal health practices, namely reduced alcohol comsumption, better eating habits and increased physical activity; 67% of them attributed changes to their increased awareness of health risks. In response to combined health promotion activity in legislation, taxation, and public education, the percentage of Canadians 15 years and older who smoke regularly has dropped from 61 to 31% for men and from 38 to 28% for women. To explore future directions in health promotion, building consensus on priorities for action and ensuring forward movement into the next century, the Perspective's Project -a two-year initiative undertaken by the Canadian Public Health Association, with support from Health Canada- culminated in 1996 with the release of the Action Statement for Health Promotion in Canada, which reinforces the relevance of three of the health promotion strategies in the 1986 Ottawa Charter: building healthy public policy, strenghthening community action, and reforming Canada's health system.

6.2 Maternal and child health-family planning (family and reproductive health). Prenatal care is universally available in Canada, and also the vast majority of women consult with trained personnel at some point during their pregnancy; 98% of deliveries are attended by physicians. Although most children in Canada are doing very well, it is clear that some children are not experiencing improvements in health and well-being. The problem of low birth weight has not abated over the last decade; there is a higher rate of infant mortality in low income neighbourhoods than in the richer ones; all health indicators for First Nations/Inuit children are worse than the Canadian average; and child poverty persists, particularly among vulnerable groups, such as First Nations/Inuit children and those in single-parent families. Women continue to have a lower status in the workforce than do men and have substantially lower incomes; both unemployment and lower status in the workplace are associated with poorer health, including sexual and reproductive health. The majority of young people in Canada believes that they have no risk, or a low risk, of acquiring a sexually transmitted disease, even though 41% are sexually active. Between 1987 and 1994, the rate of teenage pregnancy rose by more than 20%, reversing the downward trend. Health system reform has meant the lenght of postpartum stay for a mother and baby has been reduced from 4-5 days in the 1970s to 1-2 days in the 1990s. The disease focus on reproductive health has contributed to high rates of caesarian births and overuse of technologies such as ultrsound and fetal heart monitoring; hysterectomy rates also are high. The transition from a disease to wellness focus is evidenced by the growing acceptance of midwifes. To ensure that maternal and child health will have continuing desirable influences on health, Health Canada is developing a comprehensive Framework for Action on Sexual and Reproductive Health to guide the future planning of policies and initiatives dealing with these issues, addressing societal values, sexual violence, risky sexual behaviour, healthy sexual relationships, preconception health, pregnancy and childbirth -including unintended pregnancy, sexually transmitted diseases, infertility, menopause and related issues. There have also been a number of federally sponsored programs, such as the Postpartum Parent Support Program, the Nobody's Perfect Parent, Education and Support Program, Injury Prevention Program, among others aimed to positively influence maternal and child health.

6.3 Immunization. National estimates of immunization coverage in Canada are assessed at two years of age, on the basis of biennial birth cohorts: 60% of these children have been fully immunized (1993-94) according to national immunization policy; 4 doses each of diphtheria, tetanus, pertussis, and Hemophilus influenzae b (Hib); 3 or more doses of any combination of injection or oral poliomyelitis; at least one dose of mumps and rubella; and at least one dose of measles vaccine after the first birthday. The low level of coverage for the combination of routine chilhood vaccines is attributable in part to the relatively recent introduction of Hib conjugate vaccines in 1992 as part of the national program and to delayed receipt of the 18-month boosters for diphtheria, tetanus, pertussis and Hib; however, coverage for the primary series of individual vaccines is very high (at least 95%); immunization statistics are not as positive for First Nations/Inuit children (ranged from 12.5% to 84.9%). Two positive changes are noteworthy: the reduction of more than 85% in the reported incidence of Hib disease in Canada subsequent to the introduction of the Hib vaccine, and the significant interruption of measles transmission that follows the introduction in 1996 of a routine two-dose measles vaccination program to replace a one-dose strategy. Several factors inhibit immunization coverage in First Nations/Inuit communities and improvements have been and are being made using a variety of techniques; however, there has been no enthusiasm in community health nurses to reinstate routine home visiting.

6.4 Prevention and control of locally endemic diseases. The expanding numbers of infectious disease threats associated with increasing rapid international movement and transportation of growing numbers of people and commerce represent formidable obstacles to preventing or reducing the importation of serious communicable diseases. As a result, the Laboratory Centre for Disease Control (LCDC) is monitoring and conducting surveillance of international disease trends, strenghthening links with international surveillance networks, and mobilizing international strategies to control disease outbreaks. The prevention and control of locally endemic diseases have focused on HIV/AIDS; the LCDC continues to monitor and investigate the multiple dimensions of this pandemic.

6.5 Treatment of common diseases and injuries. In 1995, Health Canada made a commitment to strengthen and expand its national surveillance, disease prevention, and control capacity in order to address identified surveillance gaps and to strengthen other priority programs. New information is being generated and analysed, on the broad range of intelligence required for evidence based decisions: incidence, trends and burden of disease, new health risks, health determinants and outcomes and evaluation of preventiona and disease control interventions. Targeted public health areas included cancer, non-intentional and intentional injuries, diabetes, blood-borne pathogens, perinatal health surveillance, cardio-respiratory disease, sexually transmitted diseases, infectious respiratory diseases and tuberculosis, mental health, nosocomial infections and occupational health, emerging pathogens, food-borne and enteric diseases, vaccine preventable diseases in infants and children, laboratory diagnostic and surveillance, field epidemiology, and international surveillance.

7. Trends in health status

7.1 Life expectancy. Since the second evaluation of the strategy for health for all, longevity of Canadians has increased, as a consequence of improvements in living conditions, diseases control and health care: the average life expectancy at birth for a male is 75 years (at age 65 is 15.7 years), and for a female 81 years (at age 65 is 19.9 years). At all ages, females have a greater total life expectancy than males, although the 6-year advantage that exists at birth declines to a 3-year advantage upon reaching age 75. To some extent, this advantage with respect to length of life is offset by a lower quality of life, as the additional years lived by a woman are frequently accompanied by an increasing degree of poor health: in comparison to men, women can expect only to live an additional 1.5 years free of disabling health problems and an additional 5 years equally divided between slight, moderate, and severe disability. However, the data also reveals that augmented smoking rates among women and improved health behaviours among men are narrowing the longevity gap between the sexes.

7.2 Mortality. In 1995, the infant mortality rate was 6.1 per 1000 live births (6.7 for males and 5.5 for females), 12% lower than 1991 rate (6.9). Maternal deaths are almost nill: in 1995 there were 17 deaths (0.45 per 10.000 live births). With the exception of HIV/AIDS, none of the global target diseases and causes of mortality (acute respiratory infections, diarrhoeal diseases, malaria, and vaccine-preventable diseases) represent a major public htalth concern in the country. Moreover, since the Second Evaluation, the rate of death due to predominant causes of mortality has declined, especially deaths attributable to heart disease or injuries, due to a combination of factors. Two exceptions to the positive trend are the fairly stable death rates due to cancer and suicide. Although the overall cancer death rate has not changed, a few types of cancer are increasing and others are becoming less common. Most notably, the rise in lung cancer and the aging of the population have offset reductions in death rates for cancers such as leukemia and colorectal cancer. While lung cancer incidence rates for men have levelled off in the mid-1980s and show a small decline, for women it continues to climb steadily; in women 50-59 and 60-69, lung cancer deaths now exceed breast cancer deaths. Most suicides are concentrated in the 20-44 year old age group, but there has been a steady and significant increase in the rate of suicide for youths aged 15 to 19: the current rate of 13 per 100.000 population aged 15 to 19 is almost twice the 1970 rate; males are also four times as likely a females to commit suicide.

7.3 Morbidity. The rate of low birthweight has remained stable since the 1980s: 6% of all babies born in Canada. In general, communicable diseases causes fewer deaths than in previous generations; diphtheria, tetanus and polio have been virtually eliminated in Canada; measles, rubella, and mumps have been greatly reduced. Nevertheless, cases and outbreaks of vaccine-preventable diseases still occur on a sporadic basis. Illnesses associated with contaminated food and drinking water continue to occur; but, between 1986 and 1993, the annual rate of reported cases of intestinal infections -salmonellosis, campylobacteriosis, giardiasis- remained fairly stable at 125 per 100.000 population. Since 1980, gonorrhoea and syphilis rates have declined, but the rate of chlamydia has remained high. New diseases that have emerged in North America as a public health threat include Lyme disease, hepatitis C, and hantavirus. Six percent of Canadians aged 18 and older reported experiencing a major depressive episode, while another 3% indicated a tendency toward depression; prevalence among women (7.3%) was twice that of men (3.7%); for both sexes, the incidence of depression declined with age. The incidence of dementia is also on the rise: 8% of Canadians aged 65 and over suffer from Alzheimer's disease or some other form of dementia. Although the trend in overall work-related injuries suggests a modest reduction, Canadians still experience a significant number of work-related injuries that result in compensation: in 1993, there were more than 423.000 work injuries, a rate of almost 1 for every 25 workers.

7.4 Disability. The functional health status of Canadians in general aged 12 years and over has been assessed based on self-report data on vision, hearing, speech, mobility, use of hands and fingers, memory and thinking, feelings, and pain and discomfort. According to the 1994-95 NPHS, most Canadians are either in perfect health or have minor problems that can be fully corrected, for example near-sightedness and slight hearing loss; the average Canadian aged 15 years and over reported almost one disability day in the previous two weeks, a substantial increase over the figures reported in previous surveys. Just over 4.5 million Canadians aged 12 and older (16%) cite a health problem as reason for a disability, handicap, or impairment of daily life; causing conditions include non-arthritic back problems (17%), vision or hearing difficulties (17%), respiratory/digestive conditions (9%), and heart conditions other than coronary heart disease (7%). The government has intervened to help reduce the causes and impacts of disability.

8. Outlook for the future

8.1 Overall assessment and strategic issues. Many health indicators testify to the fact that Canadians have a standard of health that is among the best in the world. Educational levels for the population as a whole are rising; fewer persons over the age of 65 years live in poverty; more people also benefit from well developed social support networks, at both the individual and community level. Canadians generally live longer, fewer infants perish in the first year of life, and less adults die of heart disease or injuries. In fact, death rates have declined for most major diseases due to the reduced overall occurrence of these illnesses and improved treatments; in addition, Canadians today spend about 90% of their lifespan free from disabling health problems. This being as it may, the government is concerned that this high standard of health is not shared equally by all sectors within the society. Better living and working conditions are associated with better health: the affluent are healthier than the middle-class who are, in turn, healthier than the poor; the well-educated are healthier than the less-educated; the employed are healthier than the unemployed. Sadly, these disparities continue to persist in what is considered to be one of the healthiest countries in the world. The government of Canada remains firmly committed to preserving and enhancing its single-payer public health insurance system. This system is anchored in five fundamental principles set out in the Canada Health Act: universality, accesibility, comprehensiveness, portability and public administration. Canada's committment to Medicare is grounded in the system's two key strenghts: ints reflection of the fundamental equity values held by Canadians and its inherent economic logic. At the same time, it is increasingly evident that Canada's health system must evolve to meet contemporary needs. These concerns, along with technological advances and novel ethical issues, are flowing into a public arena that must equip itself to engage in a fundamental rethinking about the essential nature, organization and delivery of health services.

8.2 Futures vision. Preserving and enhancing Canada's universal health care system in the new millenium is Canada's paramount objective. Two complimentary strategic health objectives are: i) given the spending parameters identified, Canada's ability to sustain Medicare for the future means that costs and demands arising from within the system must be reduced; and, ii) at the same time, the need to decrease costs and demands arising from outside implies a better balance between health care and health promotion and prevention activities.

8.3 Proposed strategies. Strategies to reduce costs and demands from within Canada's health care system are already under way; for example, to bring the biggest cost driver, drugs, under control; and to develop a stronger evidence-based decision making culture. Strategies to achieve a better balance between heath care and health promotion and prevention are also been implemented; for instance, the framework and strategic directions in the Report on the Health of Canadians were adopted by all levels of government in 1994: this work is an important basis for the future policy development and programming in the area of population health. In addition to moving forward on these strategic fronts, in collaboration with provincial and territorial governments, the government will continue to work on the development of a federal/provincial/territorial vision of health.