The real 'two-tier' health care divide

The following article first appeared as an 'op-ed' in the National Post on August 26, 2004. The author is Dr. K.V. Nagarajan, a CRaNHR Faculty Investigator. The views expressed in this article are those of the author and do not necessarily reflect the positions of CRaNHR or Laurentian University. CRaNHR thanks the National Post for permission to post the article on the CRaNHR website.

The real 'two-tier' health care divide

National Post
Thursday, August 26, 2004
Page: A18
Section: Comment
Byline: K.V. Nagarajan
Source: National Post

'If there is a two-tier medicine in Canada, it's not rich and poor, it's urban versus rural." So reports Dr. John Wootton, Special Advisor on Rural Health to Health Canada. About 30% of Canada's population lives in rural and remote communities -- including more than half of Canada's aboriginals. As they prepare to discuss health care at their upcoming summit in September, Paul Martin and the premiers should understand that these people are not getting the health care they deserve.

As the 2002 Kirby Panel Report noted, Canada's rural populations are older, sicker, poorer and more accident-prone than their urban counterparts. Their health care needs are different from those in densely populated areas. Overall, rural-area populations possess lower educational levels and suffer higher rates of unemployment.

Despite the Canada Health Act's guarantee of reasonable access to insured health care services to all Canadians, rural residents have access to only a narrow range of services. They have to travel long distances (weather permitting) to attend to any serious illness, with their expenses only partially covered. In some cases, facilities are substandard. The problems are further compounded by the closure of rural hospitals in many parts of the country. Another serious problem is the shortage of health personnel, especially physicians: Waiting times mean little when there is nothing to wait for.

The Romanow Commission's report, also released in 2002, echoes the view of rural physicians that "geography is a determinant of health" and identifies a down-sloping gradient in health status depending on how far away a community is from an urban area.

Noting that there is currently no coherent national, pan-Canadian approach for addressing rural health issues, the report calls for developing a vision "where Canadians living in rural and remote regions and communities are as healthy as people living in metropolitan and other urban centres."

In order to convert this vision to reality, the report recommends the establishment of a "Rural and Remote Access Fund," assigning a co-ordinating role to the federal government while retaining the operational functions within the provinces, as constitutional consideration require. It proposes an immediate cash injection of $1.5-billion into the fund, and calls for an additional cash investment of $6.5-billion by 2005-2006.

The 2003 federal budget was touted as a "health care" budget because it came in the wake of the Romanow Report and attempted to give shape to many of its recommendations. But the Rural and Remote Access Fund was missing -- with no explanation from Ottawa as to why.

If the objective of government health policy is to improve the overall health of Canadians, it cannot be done by neglecting the health care needs of roughly one-third of the Canadian population. A vision for a healthier Canada must include a vision for healthier rural and remote communities. As Jose Amaujaq Kusugak of the Inuit Tapiriit Kanatami put it in a public hearing before the Romanow commission: "The success of our health care system as a whole will be judged not by the quality or service available in the best urban facilities, but by the quality of service Canada can provide to its remote and northern communities."

With regard to how new money would be spent, many of the needed policy solutions are already known -- for they are contained in a 2002 report prepared by Health Canada's Ministerial Advisory Council on Rural Health. Titled Rural Health in Rural Hands, the report calls on the federal government to work with the Conference of Deputy Ministers of Health to establish a focal point for developing rural health research, telehealth networks and a nationwide human-resources policy for health workers. For aboriginal communities, it advocates community-based health promotion and disease prevention programs to be developed and implemented by the aboriginal communities themselves. The report also makes suggestions as to how governments can encourage the training and support of effective rural health teams that include practitioners from a wide range of health professions.

While many pundits focus on private versus public health care, Mr. Martin and the premiers should focus on a brand of "two-tier" medicine that is of even greater serious concern to the one in three Canadians who lives outside a city. As a starting point, the Rural Access Fund may be an excellent -- and, compared to pharmacare, relatively cheap -- way to proceed. For several years now, the challenges have been documented, and solutions proposed. Rural Canadians are now eager to see some action.

Note: K.V. Nagarajan is an associate professor in the Department of Economics at Laurentian University in Sudbury, Ont. A longer version of this article appeared in the Canadian Journal of Rural Medicine.