Arbitrary data and privatization harm human health resource planning: doctors, experts
Canadian Doctors for Medicare recently hosted a thought-provoking webinar on ideas for solving problems related to health care providers in Canada that is available for viewing here –
Dr. Isser Dubinski held the audience’s attention with his “ten uncomfortable truths about human resources planning” as did his personal story of having to access health care as a child in a family that struggled to pay for food and rent.
“In a private-public mix or in a private delivery system, people who can’t afford health care will sacrifice to pay their bills. I don’t think anybody should… I’m unshakeable on the issue,” Dr. Dubinski told the audience.
Similar to Dr. Dubinski’s childhood experiences, Tommy Douglas, considered the founder of Medicare in Canada, grew up needing costly treatment for osteomyelitis in his leg. Douglas’ family could not afford to pay for immediate treatments and young Tommy almost lost his leg due to the delays. The experiences made Douglas a firm believer in universal, public health care.
Dr. Dubinski is with the University of Toronto’s Institute of Health Policy, Management and Evaluation. He said his list of truths stem from his extensive clinical experience in rural health care and city emergency departments as well as from his consultant and academic work on health care.
According to Dr. Dubinksi, there is a no health provider shortage but rather a problem with the distribution of health providers.
“We have no national health human resource plan.”DR. ISSER DUBINSKI
Joining Dr. Dubinski on the panel were Dr. Ivy Bourgeault, a faculty member of the School of Sociological and Anthropological Studies at the University of Ottawa, and Dr. Alika Lafontaine, president of the Canadian Medical Association.
The panelists all agreed that the “arbitrary nature” of definitions and data in health human resource planning is a problem.
“We haven’t identified what it means to be healthy,” said Dr. Lafontaine. For Dr. Lafontaine, being healthy is not the absence of disease. He elaborated on the role of community in keeping people healthy.
Dr. Lafontaine said we must come up with shared definitions in health human resource planning, and recognize “our past solutions are actually our current problems.”
The anesthesiologist spoke against what he called a knee-jerk response to inadequate access to surgical care being to open a non-hospital surgical facility. “That’s just creating more problems. It’s creating more fragmentation,” said Dr. Lafontaine.
Bourgeault said the definitions and measurements in use are problematic ways to approach heath care problems. Bourgeault called for “more robust measures of capacity” and standardized data across the country and across professions.
“Who is providing clinical services and what is their capacity to deliver services? Surely, in 2023, we can apply some measures to come up with what is a full-time up equivalent. And we can say who is the population and how is the population different?” argued Bourgeault.
In a similar vein, Dr. Lafontaine argued for a data system that matches what people can give with what is needed to work towards a redistribution solution.
For Dr. Lafontaine, fragmentation, over-segmentation and uneven modernization in health care are at the core of the health human resource crisis.
Solutions to the problem of inadequate specialist care
Access to specialist care is a problem across Canada, especially in provinces like Prince Edward Island and Newfoundland and Labrador, and the territories. “We have no national health human resource plan,” stated Dr. Dubinksi.
Dr. Dubinski asked the audience to consider whether inadequate specialist care is a result of a problem in primary care training, a failure to integrate non-MD professionals into integrated models of care, or a problem of specialist appointment training.
Primary care is a place to start to resolve health human resource planning problems, according to Bourgeault. In her studies of primary care in Toronto neighborhoods, she has found those areas with the lowest proportion of people having access to a primary care provider have the highest proportion of presentation of non-urgent symptoms at emergency rooms.
“More than six million Canadians do not have a primary care provider. This makes us look like we don’t have universal access to health care,” said Bourgeault.
For Dr. Dubinksi, two primary care models that are close to ideal and worth examining are the community-health centres in Ontario and the Algoma Clinic that provide an integrated model of care.
“I believe we have failed to build team-based approaches to care,” said Dr. Dubinski who also wants the approach to health human resources planning to use of data/evidence-based/best practices models of care.
“We must fundamentally revise models of training” and “expand post-graduate positions in geriatrics,” added Dr. Dubinski. The doctor says Canada needs an integrated, coordinated and comprehensive approach to elderly care.
Speaking at an event organized by doctors and allies that champion public health care solutions, Dr. Dubinski said he is against the endless expansion of medical schools and instead wants enforcement of physician responsibility and accountability that ensures physicians live up to their contracts for the provision of services.
The need for a gender analysis in Canada’s health workforce is a recommendation that gender specialists such as Bourgeault champion.
“The health workforce is where most women work. In Canada, over 80 per cent of health care workers are women. That proportion is higher than the global average of 70 per cent,” noted Bourgeault.
Bourgeault referred to the “gender leadership pyramid in health care” where those who represent the sector, including deans of faculties of medicine, are predominately those who identify as male while those doing the frontline care work are women. Women are overrepresented in the frontline health care workforce, including nursing, midwifery and dental hygiene.
Referencing a recent study in Health Policy that revealed a wide gender pay gap for doctors in the higher billing range in Canada, Bourgeault noted, on average, women in the lower half of the billing range, are consistently billing 6 to 10 per cent less while in the higher range, women are billing 15-20 per cent less.
“Gender absolutely matters. Gender matters within medicine. Gender matters across the health workforce. Gender matters to leadership. Gender matters to planning. Gender matters in addition to all the other important intersections–racialized identity and Indigenous identity,” remarked Bourgeault.
The ethics of international recruitment of health personnel
International recruitment of health care workers is sometimes proposed as a solution to Canada’s health human resources problem. Dr. Dubinski and Bourgeault raised concerns with this approach.
“We have to avoid the temptation of pilfering resources from under-resourced countries,” said Dr. Dubinski.
Bourgeault noted Canada has signed a global code of practice for international recruitment on health personnel that includes a core principle to collect better data for robust planning so that countries can move towards more self-sufficiency.
Privatization is not the solution
In the discussion period, Dr. Lafontaine said we need to move away from paying out-of-pocket for health care. “Governments need to step up and be part of the conversation,” said Dr. Lafontaine.
“The more you move providers and services into the private sector, the less likely you will have data for planning.”IVY BOURGEAULT
Bourgeault added, “Privatizing a service never increases the capacity of the health care workforce to provide those services ever… That’s just magical thinking.”
“Moving services into the private sector moves data into the private sector,” said Bourgeault which she described as “the wild west.”
“The more you move providers and services into the private sector, the less likely you will have data for planning,” added Bourgeault.
Who are the Canadian Doctors for Medicare?
Canadian Doctors for Medicare formed in 2006 to oppose increased privatization in Canadian health care. Their members include leaders in clinical medicine, research, policy and education residents, medical students, retired physicians, and “friends” in other health professions and among the Canadian public. They support reforms to Medicare within the public system.
Tracy Glynn is the National Director of Projects and Operations for the Canadian Health Coalition