Don’t let good health reforms fade or fossilize

When Canada’s health ministers left Winnipeg on Oct. 16, they took with them a promise to keep talking. The federal health minister did not commit to long-term funding. She offered one-year extensions for programs that were about to run out, and asked officials to begin work on “the next 10 years.”

The provinces, in the words of Manitoba Health Minister Uzoma Asagwara, wanted to avoid “fiscal cliffs” and needed “predictable, stable, sustainable funding.”

Both sides have a point. And both are talking almost entirely about money — how much, for how long, under what formula.

Missing from the conversation is the question that decides whether any of it works — once the money flows, who must answer for what it does, or does not, achieve? We have been here before. In 2002, a Senate committee chaired by Michael Kirby warned that new federal money “must be used to buy change, not merely to support the system as it is presently structured.” It proposed an independent national health care commissioner, reporting every year to the public on how the system and the health of Canadians were faring.

It proposed a guarantee: public maximum waiting times, with governments obliged to pay for care elsewhere when those times were exceeded. And it noted that none of this required any change to the Canada Health Act.

Some of it was built. The 2003 health accord created the Health Council of Canada to report publicly on progress. But its members were government nominees, Quebec stayed out and, while it reported to the public, no government was obliged to respond to what it found. When the 10-year agreement expired in 2014, federal funding for the council ended on the grounds that it had completed its mandate. No federal government since has restored it. The watchdog belonged to the deal it was watching and it ended with the deal.

Reforms in Canadian health care fail in two ways. Some fade — bills die when Parliament is prorogued, councils lapse when their funding ends, programs live from one extension to the next. Others fossilize — they stay on the books but no longer act.

The Canada Health Act shows the difference. Where it is specific, it works — when patients are charged for medically necessary care, Ottawa deducts the amount from the province’s transfer, more than $62 million in 2025 alone, and returns it to the province once the charges end. The money moves between governments; the patients who paid the charges are not part of that exchange. But for 40 years the Act has also allowed Ottawa to reduce transfers to a province that breaches its broader principles, including reasonable access. That discretionary power has never been used. Fading and fossilizing have the same cause. No office is required to answer for the result.

The same pattern plays out inside provinces. In 2003, an external review of cardiac services in Manitoba, the Koshal report, made 42 recommendations. Most within the program’s own reach were carried out, and by 2017 the program was among the best-performing in the country, and perhaps the most fragile.

The recommendations that depended on the province, its regional health authority and the university were never acted upon, including the one that would have protected the program — a service agreement holding it answerable for its results. Since then, the structure that made it strong has been allowed to fade, one unfunded position and one lapsed process at a time, as competing priorities took precedence. A program that succeeds in spite of the system, rather than because of it, lasts only as long as the people who carry it.

The federal minister says it is time to “change the way we are doing things.” She is right, and the next 10-year agreement is where to do it. Every commitment in it should answer four questions: Who owns this outcome? What standard will it meet, defined by what matters to patients? Who will report on it, publicly, and when? What happens if it is not met?

Consequences should be graduated — a published shortfall first, then a remediation plan, then independent review, with money last. A penalty too large to use protects no one.

And the monitor must outlast the deal. The Parliamentary Budget Officer, created by statute in 2006, has survived every change of government since then because it does not depend on the goodwill of those it reports on. A health-care monitor built the same way, in Ottawa or in any province, independent of the accord, the minister and the funding cycle, would not need to be reinvented every decade.

The provinces are right to want predictable funding. The fair exchange is predictable accountability — stable money in return for stable, public answers about what that money buys for patients.

Fairness is the promise at the heart of the Canada Health Act — care on uniform terms and conditions, according to need rather than ability to pay.

Ottawa already reports, publicly and to the dollar, when provinces break that promise by charging patients. What is needed now is a public scoreboard for value to patients, meaning the outcomes they receive for what the system spends. It would show failures of access, timeliness and quality of care, and who and what is responsible for each.

Structures exist on paper. Patients experience care in real time.

Alan Menkis is a retired cardiac surgeon, former medical director of cardiac sciences at St. Boniface Hospital, and professor of surgery at the University of Manitoba.