Effective Advocacy in
Public Health
How Do Victims of Their Own
Success Get Action?
Association of Local Public Health Agencies
January 31, 2003
Terrence Sullivan PhD
Cancer Care Ontario
• What Are the Current Health Reform
Imperatives?
• Where are the Promising Areas for Public
Health?
• How Does Public Health Make Itself Relevant
in Reform Planning
• What Can we Do to Raise our Profile?
Provincial Reform Exercises
• Alberta - Premier’s Advisory council
(Mazankowski)
• New Brunswick - Premier’s Advisory Council
• Ontario - Health Services Restructuring Commission
(Sinclair)
• Quebec - Commission d’etude sur les services de
sante et les services sociaux (Clair)
• Saskatchewan - Commission on Medicare (Fyke)
National Reform Exercises
• National Forum on Health
• Standing Senate Committee on Social Affairs,
Science and Technology (Kirby) - Interim Report
(v. 1-5) and Final Report (v. 6)
• Commission on the Future of Health Care in
Canada Report (Romanow)
Common Themes
•
•
•
•
•
•
•
System financing
Primary care reform
Regionalization
Pharmaceuticals
Health human resources
IT, performance measurement and quality
Governance and accountability
•
Promising Reform Imperatives - KIRBY
• Promising Reform Imperatives Cont’d
The federal government, in collaboration with the provinces and territories
and in consultation with major stakeholders (including the Chronic Disease
Prevention Alliance of Canada), implement a National Chronic Disease
Prevention Strategy.
The National Chronic Disease Prevention Strategy build on current
initiatives through better integration and coordination.
The federal government contribute $125 million annually to the National
Chronic Disease Prevention Strategy.
Specific goals and objectives should be set under the National Chronic
Disease Prevention Strategy. The outcomes of the strategy should be
evaluated against these goals and objectives on a regular basis.
The federal government ensure strong leadership and provide additional funding to
sustain, better coordinate and integrate the public health infrastructure in Canada
as well as relevant health promotion efforts. An amount of $200 million in additional
federal funding should be devoted to this very important undertaking.
CHAPTER 13 OF THE KIRBY REPORT – OCT 2002
• Promising Reform Imperatives
• Draft
In Confidence and Without Prejudice
• January 21, 2003 First Ministers= Accord on Health Care Renewal
•
Primary Health Care: Ensuring Access to the Appropriate Health
Provider When Needed………(part of the health reform funde)
•
Additional Reform Initiatives. “The federal government is committed to
providing funding in support of this work” ...:A Healthy Nation
•
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
environmental health. Health Ministers are to focus 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.
Consensus on….
• Primary care reorganization
• Regionalization of service delivery
• Population health focus
• Evidence-based decision making
• Improved information information systems
Controversy over...
• Role of private financing and for-profit
delivery
• Federal-provincial relations and governance
issues
• How Does Public Health Make Itself Relevant
in Reform Planning? Strategy:
– Hitch our Wagon to emerging reform areas where
consensus exists
• chronic disease
• healthy living
• immunization
– Weigh in on Controversial Areas
• public private issues
• fed/prov
• governance
– Be Timely and Use Policy Brokers
Public Private Muddles in Health Care
Finance
Allocation
Delivery
Public
Tax Pooling by
Provincial Health
Ministry/ Health
Insurance Plan
Provincial or Federal $
to Hospitals vs.
Community Care vs.
Education and Training
Municipal Public
Health Services
Private
Not-forProfit
Charities,
Foundations and
some Health
Research Agencies
Regional Health
Authorities to Hospitals
vs. Home Care vs.
Primary Care
Public Hospitals
For-Profit
Private Insurance
Private Group Benefit
Managers
Cosmetic Surgery
Clinics
Some Home Care
Nursing Homes
Private Labs
Managed Care
Corporations (in the
U.S.)
Community Health
Centre
Figure 1
Incidence of Taxation and Public Health Care Consumption
By Economic Family Income Decile
Manitoba 1994
10
9
(Lowest to Highest)
Income Decile
8
7
6
Health Benefit
5
Tax Payments
4
3
2
1
Inst
$0
$100,000
$200,000
$300,000
$ 000
$400,000
$500,000
Comparison of mortality
between private for-profit
and private not-for-profit
hospitals and hemodialysis
centers:
a systematic review and
meta-analysis
P.J. Devereux et al,
Hospitals: CMAJ 2002, 166:1399-1406
HemoDialyisi: JAMA, 2002, 288: 2449-2457
Relative Risk of Hospital Mortality:
Adult Patients
Number of Number of
Study Hospitals Patients % Weight
Shortell
Keeler
Hartz
Manheim MH
Manheim FS
Kuhn
Pitterle
Mukamel
Bond
Yuan Medical
Yuan Surgical
Lanska
McClellan
Sloan
653
220
2,368
1,252
1,617
2,580
3,482
1,653
3,224
3,316
-799
2,875
2,360
144,159
4,937
3,107,616
1,537,660
2,228,593
3,353,676
4,529,206
5,298,812
4,210,468
7,386,000
4,396,000
16,983
181,369
7,079
Totals
26,399
36,402,558
1.43
0.04
11.38
9.78
2.59
12.34
14.11
17.21
12.66
11.90
5.05
0.00 !
1.48
0.03
Favours
Private
Not-For-Profit
Favours
Private
For-Profit
!
!
!
!
!
!
!
!
!
!
!
!
!
100.00
Random Effects Pooled Estimate
!
0.7 0.8 0.9 1 1.1 1.2 1.3
Relative Risk and 95% CI
How important is a relative
risk increase of 2%
• Canadian statistics for 1999-2000
– 108,333 Canadians died in hospital
• If we converted our private not-forprofit hospitals to private for-profit
hospitals
– this would result in an extra 2200
deaths a year
• This increase is in the range of how
many patients die in MVAs, from
colon cancer, or suicide each year
Relative Risk of Mortality in Hemodialysis Patients
All Studies Included in the Systematic Review
Favours Private
For-Profit
Oldest Data
Newest Data
Favours Private
Not-For-Profit
Author
RR
95% CI
Plough
0.71
0.49 - 1.02
Farley
1.11
1.04 - 1.18
Garg
1.18
1.02 - 1.37
Irvin(1)
1.09
1.07 - 1.12
Irvin(2)
1.16
1.09 - 1.23
McClellan
1.09
0.83 - 1.44
Port
1.06
1.01 - 1.12
!
Irvin(3)
1.05
1.03 - 1.07
!
!
!
!
!
!
!
Random Effects Pooled Estimate for All 8 Studies
RR = 1.09 (95% CI, 1.05 - 1.12)
!
Random Effects Pooled Estimate for 4 Selected Studies
RR = 1.08 (95% CI, 1.04 - 1.13)
!
0.4
0.6
0.8
1
1.2
1.4
Relative Risk and 95% CI
1.6
How important is a relative
risk increase of 8%
• United States statistics for 2001
– 208,000 patients receive in-centre hemodialysis
– 75% receive their care in private for-profit
facilities
– 20% die every year
– Therefore likely 2,500 (range 1,200 to 4000)
excessive premature deaths annually in US forprofit dialysis centres
• Canadian statistics for 1999
– 12,715 hemodialysis patients
– 1,966 died
– If we converted our private not-for-profit dialysis
centres to private for-profit centres we would
expect approximately 150 (range 80- 250)
excessive premature deaths annually
• What Can we Do to Raise our Profile?
• Tactics:
– Dramatize Threats
• Walkerton, North Battleford,
• bioterrorism, toxic spills, rise in obesity
– Back these up with Data
– Celebrate Victories and Champions
– Define Common Agenda & Mandate Controversial and Dramatic Action
(e.g. more Pete Sarsfields!)
– Concerted Action with Province/Feds
– Effective Public Affairs Management
The growing burden of cancer in
Ontario 1990 - 2020
Annual number of cases
60,000
50,000
Incident-m
40,000
Proj-m
Incident-f
30,000
Proj-f
20,000
10,000
0
1990
1995
2000
2005
Year
2010
2015
2020
Survival following diagnosis of all cancer
sites combined by region of residence
Ontario males and females 1993-97
1.15
5 Yr Survival Rate Ratio
1.1
1.0 5
LC L
1
UCL
S ur v R R
0 .9 5
0 .9
Cancer Planning Region
SRR = the ratio of the 5 yr relative survival rate for each region divided by the 5 yr RSR for Ontario as a whole
LCL, UCL : lower and upper 95% confidence limits
Source : The Ontario Cancer Registry December 2002.
NW Regio
S Region
SE Regio
CW Regio
NE Regio
SW Regio
All know
Eastern
CE Regio
0 .8 5