Effective Advocacy in Public Health

How Do Victims of Their Own

Success Get Action?

Terrence Sullivan PhD

Cancer Care Ontario

Association of Local Public Health Agencies

January 31, 2003

• 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 territoriesand in consultation with major stakeholders (including the Chronic DiseasePrevention Alliance of Canada), implement a National Chronic DiseasePrevention Strategy.

The National Chronic Disease Prevention Strategy build on currentinitiatives through better integration and coordination.

The federal government contribute $125 million annually to the NationalChronic Disease Prevention Strategy.

Specific goals and objectives should be set under the National ChronicDisease Prevention Strategy. The outcomes of the strategy should beevaluated against these goals and objectives on a regular basis.

The federal government ensure strong leadership and provide additional funding tosustain, better coordinate and integrate the public health infrastructure in Canadaas well as relevant health promotion efforts. An amount of $200 million in additionalfederal 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

Cosmetic Surgery Clinics

Some Home Care

Nursing Homes

Private Labs

Private Group Benefit Managers

Managed Care Corporations (in the U.S.)

Private InsuranceFor-Profit

Public Hospitals

Community Health Centre

Regional Health Authorities to Hospitals vs. Home Care vs. Primary Care

Charities, Foundations and some Health Research Agencies

Private

Not-for-Profit

Municipal Public Health Services

Provincial or Federal $ to Hospitals vs. Community Care vs. Education and Training

Tax Pooling by Provincial Health Ministry/ Health Insurance Plan

Public

DeliveryAllocationFinance

Figure 1Incidence of Taxation and Public Health Care ConsumptionBy Economic Family Income DecileManitoba 1994

$0 $100,000 $200,000 $300,000 $400,000 $500,000

Inst

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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, 166:1399-1406HemoDialyisi: JAMA, 2002, 288: 2449-2457

Relative Risk of Hospital Mortality:Adult Patients

Shortell 653 144,159 1.43

Keeler 220 4,937 0.04

Hartz 2,368 3,107,616 11.38

Manheim MH 1,252 1,537,660 9.78

Manheim FS 1,617 2,228,593 2.59

Kuhn 2,580 3,353,676 12.34

Pitterle 3,482 4,529,206 14.11

Mukamel 1,653 5,298,812 17.21

Bond 3,224 4,210,468 12.66

Yuan Medical 3,316 7,386,000 11.90

Yuan Surgical -- 4,396,000 5.05

Lanska 799 16,983 0.00

McClellan 2,875 181,369 1.48

Sloan 2,360 7,079 0.03

Totals 26,399 36,402,558 100.00

0.7 0.8 0.9 1 1.1 1.2 1.3Relative Risk and 95% CI

FavoursPrivate

Not-For-Profit

FavoursPrivate

For-ProfitStudy

Number of Hospitals

Number of Patients % Weight

Random Effects Pooled Estimate

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-for-

profit 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 PatientsAll Studies Included in the Systematic Review

0.4 0.6 0.8 1 1.2 1.4 1.6

Relative Risk and 95% CI

Favours Private Not-For-Profit

Favours Private For-Profit

Oldest Data

Newest Data

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)

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 for-profit 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

4

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The growing burden of cancer in Ontario 1990 - 2020

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Cancer Planning Region

5 Y

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Survival following diagnosis of all cancer sites combined by region of residence

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.