How bilateral health accords could help improve everything from wait times to staffing shortages

The beauty of the bilateral model is that it avoids the question of “federal strings” by allowing provinces to commit to how they will move their services in the direction of the shared goals, writes Tom McIntosh.

It's time to end the debate over whether health investments should come with 'conditions' or 'strings'

A sign in front of the emergency department at a hospital that says "EMERGENCY AND ADMITTING".
Canada's health-care system needs real, substantive and measurable change, otherwise it may never recover, writes Tom McIntosh. (Ose Irete/CBC)

This column is an opinion by Tom McIntosh, a professor of politics and international studies at the University of Regina. For more information about CBC's Opinion section, please see the FAQ.

The prime minister's statement on Jan. 16 that there were "positive steps forward" toward breaking the long-standing impasse in the debate over health care financing should come as welcome news to Canadians. 

In particular, both the PM and some of the premiers seem intent on moving away from the traditional federal-provincial-territorial debate over whether new federal investments in health should come with "conditions" or "strings." Rather the talk was of "shared priorities." 

With a health-care system increasingly admitted to being in crisis and a reigniting debate over private delivery and possibly private payment for some services, this is positive news in a policy area in desperate need of some. 

Indeed, the provinces and the federal government already know how to recast the debate over "strings" and "conditions" because they have done it before. First with the 2017 health care agreements and then again in the intergovernmental child-care funding agreements signed in the past few years.

In 2017 the federal, provincial and territorial governments signed an umbrella statement of principles making the substantive reform of mental health and community-based care key priorities in Canada's health system. The federal government then signed individual bilateral agreements with each province and territory indicating, with varying degrees of specificity, how they would spend their share of an additional $11.5 billion in health spending to achieve those goals. 

Unfortunately, the global COVID-19 pandemic knocked health-care systems across the world for a loop, derailing reform efforts and focusing our attention elsewhere. But a once-in-a-century calamity should not be taken as an indication that the model was necessarily faulty at its core.

A highly-fractured system

This approach to intergovernmental diplomacy had the advantage of recognizing that the provinces were in different places in terms of how they designed and delivered services. As the president of the Canadian Medical Association, Dr. Alika Lafonfaine, recently argued, the system is highly fractured, operates in silos and lacks coordination.

As we know from the relative failure of the 2004 Health Accord — the so-called "fix for a generation" — simply agreeing to transfer large sums of money in furtherance of real change has not worked. The current provincial demand for a $28 billion unconditional increase in the Canada Health Transfer (CHT) would do little to solve the system's problems. 

Indeed, there is good reason to believe that putting that amount of cash into the system without clear and specific goals about what one wants to achieve might only make the situation worse. 

It is easy to see billions of dollars wasted as provincial and territorial governments compete against each other for scarce health human resources, succeeding in only bidding up the price of health-care workers.

But if the governments start with shared priorities — say, for example, a coordinated approach to health human-resource planning, the management of wait times and the expansion of primary health-care teams — and then set about outlining how each government would use their share of any new funds to further those goals, then there could be some optimism about affecting real change in those services. 

The beauty of the bilateral model is that it avoids the question of "federal strings" by allowing provinces to commit to how they will move their services in the direction of the shared goals. In other words, the provinces set the conditions themselves, tailored to reflect the particular situation of each province and territory.

Clear and transparent reporting

Of course, the sticking point will be how we assess whether change is happening. This would require the provinces and territories to agree to provide clear and transparent reporting to their residents about how the money was spent (something that was sadly missing from the 2017 bilateral agreements). 

In December, Nova Scotia Premier Tim Houston indicated a willingness to make such a commitment and Ontario's Doug Ford and Quebec's François Legault made similar pledges.

As of yet, no one knows whether what Canadians will see will be another "grand bargain" like in 2004, or whether the bilateral deals of 2017 will be the template. But as is often the case in intergovernmental diplomacy, what may look like a last minute deal that went down to the wire was in fact the result of far more behind-the-scenes negotiating than we knew at the time. 

Regardless, what must come out of the deal is real, substantive and measurable change. Bilateral agreements around a shared plan may be the best way to get there. Otherwise Canada's public health system may never recover.

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Tom McIntosh

Freelance contributor

Tom McIntosh is a professor of politics and international studies and a researcher at the Saskatchewan Population Health and Evaluation Research Unit (SPHERU) at the University of Regina.


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