The following is an excerpt from Volume 28, Issue 4 (March 2001) Introduction Across Canada and in other countries, access to health services at an affordable price is a priority issue. Federal and provincial politicians war with each other over funds and credit, health professionals are caught in the middle and the media contributes more heat than light to the situation. The public, whom each protagonist earnestly claims to serve, is generally ignored as an active player and resource. I propose that we cannot resolve Canada's healthcare issues cost-effectively unless we engage more informed and responsible citizens as partners in this enterprise. In this paper, after a brief review of some history and a summary of some data on public attitudes, knowledge and behaviour, I invite you to reflect on (a) the publics for health, (b) an effective model of public management and (3) citizen engagement as a way for the general public to become an informed and effective contributor to improving the health and well-being of all. And at a price we can afford. Citizen engagement, a fairly new concept to add to the widespread lexicon of public involvement (generic term), public consultation (advisory) and public participation (power-sharing), will be featured in a new form. Some History From earliest times, doctors established their practices on a fee-for-service basis and hospitals were established by religious organizations or local charitable foundations. In 1867, the new national constitution defined healthcare as a family or local concern and made the provinces responsible for it. In 1948, Saskatchewan premier Tommy Douglas introduced universal hospital insurance in the province and the federal government implemented the Health Grants Program, with 50-50 cost sharing with the provinces, leading to a national health insurance plan. In 1966, the federal Medical Care Act covered doctors' services. By 1972, all provinces participated in Canadian healthcare. Following the recommendations of the 1980 Hall Report, the Canada Health Act (1984) consolidated previous legislation and affirmed the five criteria for Canadian healthcare - it must be comprehensive, publicly administered, universal, portable and accessible. In 1991, a federal parliamentary committee concluded that problems with the healthcare system cannot be resolved by increased spending; more cost-effective solutions are needed at community and local levels. In 1995, the government announced a new, and reduced, federal funding formula, the Canada Health and Social Transfer. Cutbacks required to deal with federal fiscal deficits resulted in reduced levels of health services; as visible problems emerged, public protests and provincial demands led to the restoration of federal funding. Shortages in services are not yet fully repaired. e.g. there are emergency room overcrowding, long wait lists, local doctor deficits, bed shortages in hospitals, etc. (1). What is Health? A recent Health Canada working paper, "Population Health in Canada", moves on from "health is the absence of disease" to defines it as "the capacity of people to adapt to, respond to, or control life's challenges and changes" (2). This formulation recognizes that health depends on personal circumstances and social, cultural, economic and environmental influences. The New Brunswick Division of the Arthritis Society of Canada, in a recent submission to a N.B. Select Committee enquiry, defined "Wellness is a state of emotional, mental, physical, social and spiritual well-being that enables people to reach and maintain their personal potential in their communities." (3) Public Attitudes, Knowledge and Behaviour In the last Maclean's Global Poll in December, 2000, 35% of adult Canadians say that healthcare is the most important issue facing Canada today (54% in the Atlantic region, 45% in B.C. and 23% in Quebec; 47 % of women, 30% of men); in contrast, unemployment rates just 11% as the #1 issue across Canada. Some 54% would accept moderate user fees and 47% would agree to a parallel private system for those who can afford it; 81% believe the latter will occur within a decade. (4) Some 93% of women and 83% of men say they are satisfied with the medical care they received last year, according to the Globe and Mail, Dec. 30, 2000. In a major health study published in 1999 (5), 25% assess their health and well-being as "excellent" (same as 1985), 38% as "very good" and 9% as "fair to poor". Regarding attitudes to work, half of the working population say they are very satisfied with it (down somewhat from 1985, especially amongst women). While happiness used to decline with age, in the `90s it seems to increase. Those with higher social status report higher levels of health, self-esteem, sense of mastery and job satisfaction; there are no great differences by province. High life stress is reported by 26% of adults, ranging from 17% in Newfoundland to 28% and 29% in Ontario and Manitoba respectively. High work stress is indicated by an average of 4%, including 13% of females 20-24. The study assesses health knowledge as a major factor in choices for healthy behaviour, but recognizes that health decisions are affected by the desire for pleasure, modelling in the media, peer pressure, addiction etc. While most know about the hazards of smoking, there is growing skepticism about the danger of secondhand smoke. Levels of knowledge about nutrition and terminology are low and have declined since 1994, perhaps affected by controversies about dietary fat. Knowledge about the relationship between diet and disease is termed "tenuous", though two-thirds claim that nutrition is very or extremely important in their choice of foods. Amongst healthy behaviours reported, 59% avoided products for environmental reasons, 51% gathered information on environmental issues, 28% supported environmental groups, 88% recycled or composted, 42% have home water purifers and 40% buy organic foods. In leisure time, 21% are classified as active, 23% as moderately active and 57% as inactive; this is much the same as a few years earlier. While 59% are concerned about dietary fat, only 26% are both concerned and active about their starch and fibre intake, with 17% being concerned but inactive and 57% unconcerned. Consumption of butter, oil and salad dressing has been reduced by 81% of the population, fried food by 78% and high fat milk by 72%. In general, 47% report changing some behaviours to improve their health and 54% recognize the need to do so; 69% say "next year". Unmet health needs in the previous year were reported by 5% (1.2 million); they required some health care or advice in the previous year but did not receive it. Some 78% of the cases were for physical health needs and 9% each for emotional health and injuries. Social support - access to friends and family in times of need - was widespread; 83% report access to four of five sources. However, this was least reported by those who need it most - seniors, low income people and single parents. In practice, only 3% received informal care for a long-term health problem and just 2% used home care. Though 16% report long-term disability, the use of self-help groups is rare. The provision of informal care to others is limited by the stress and job repercussions it generates; caregivers need supplementary help. This is especially true for the sandwich generation (aged 35-54) who are caring for both their own children and their aging parents. In 1996, 38% provided some unpaid child care, 17% aided seniors and 12% helped those with long-term health problems. Publics for Healthcare A "public" is a set of people who share a common perspective on an issue. Thus the publics for health care include citizen-taxpayers, current patients, former patients, potential patients, patient's families, physicians, nurses, administrators, ancillary professions e.g. occupational therapists, and many more. Surveys can identify the knowledge, attitudes and behaviour of each of these with regard to health. i.e. about their personal situation and the state of the healthcare system. However, I think another type of analysis is relevant and useful - to assess the general public in terms of (a) citizens' knowledge about health and the healthcare system, and (b) their motivation for action about health and the healthcare system. A 2 x 2 table generates the following: Informed Actives (IA) These people are informed about health matters and the system; they are also keen to do something about both their own health and the reforms needed to make the healthcare system work better. Uninformed Actives (UA) While motivated, these people lack a knowledge base about health and the system. They are the kind of "loose cannons" who are easily taken in by a food fad, a single factor theory about weight loss or an ill-conceived proposal to reform the healthcare system. Informed Passives (IP) These people are knowledgeable but lack the will to take action, both about their own health and the system; they are among the 69% who say they need to change their health behaviour and will do it "next year." Uninformed Passives (UP) These are the classic dependent patients who seem to neither know nor be concerned about their personal health or the healthcare system. What proportion of our Canadian population are in each cell? Perhaps some of those who work in health promotion and health research can make some educated guesses. Strategically, what can be done to move more people into the IA cell? Motivation, I believe, is the most critical variable. Let's examine a model of public management. A Model of Public Management The goal of a provincial Dept. of Highways is to enable drivers to move from one location to another, safely, efficiently and effectively; the rights of cyclists and pedestrians must, of course, be respected. To achieve this goal, citizens must accept the rules of the road; they must also accept personal responsibility for their knowledge base and driving behaviour. A core of essential information and skills is tested before a driver's licence is issued; it can be suspended or taken away permanently for bad driving. In some jurisdictions, tests are carried out annually on a vehicle's lights, brakes and exhaust emissions; a certificate of roadworthiness is required. Motivation is pursued systematically. Good drivers are rewarded by reduced annual insurance fees. Bad drivers receive demerit points and may suffer court judgments, including surrendering their driver's licence. Beyond policing, there is general agreement amongst drivers about what constitutes good driving behaviour; most people follow it most of the time. e.g. the incidence of drinking before driving has been falling. Probably more than 90% of drivers are IAs; UAs will be very few. Most IPs and UPs will be passengers, pedestrians and transit users. Highway authorities treat drivers as adults, while the healthcare system treats citizens like children who lack information and the ability to take responsibility for their actions. In B.C., driver's licences are held by 63% of those 21-60 years, 6% of 16-20 year olds and 31% of those 61 years and over. What makes the public management of drivers work? Here are some components: clear and agreed goals and rules of the road; a minimum and tested level of driving literacy; strong motivation, both positive and negative. It's not exactly rocket science, is it? Could this kind of public management system be applied to healthcare? The Strategic Management of Health I believe that the objective of public involvement, whatever form it takes (consultation, participation or citizen engagement), is to develop informed, visible, majority public understanding, acceptance and support for a viable proposal. Before discussing alternative ways of public involvement in health, deficits in public knowledge and motivation must be addressed to ensure that the majority of adult citizens are IAs. Knowledge Basic health literacy requires that citizens know 10 - 20 key facts, concepts and numbers about health. Passing a health literacy test could be part of applying for membership in a provincial medical services plan. Most citizens don't know the cost of the various health services and products they receive through a government plan. Without this information, how can they be responsible consumers? With the digital technology we have today, each citizen could receive an itemized pro forma invoice in January for the health costs they incurred during the previous year. Motivation While life insurers give preferred rates to applicants who are an appropriate weight, non-smokers etc., all pay the same rate for their provincial medical coverage. There is thus no incentive for healthy behaviour. Some time ago, I read a proposal which would allow each person a basic $2,000 for health costs annually, plus a lifetime $50,000 allowance for major medical expenses. At the end of each year, whatever was not used of the $2,000 would be divided into (a) a contribution to add to the individual's major medical fund, and (b) a cash rebate. This incentive, the writer suggested, would foster the cost-effective use of health services and products, including reducing the use of the Emergency Depts. of hospitals, especially on weekends. Should the unfit, overweight smoker who abuses alcohol and other drugs pay the same medical services plan premium and have equal priority access to scarce hospital beds and overworked services? Citizens and the healthcare system accept "lifestyle diseases", also called the Diseases of Civilization, e.g. cardiovascular problems, cancer, diabetes etc., with equanimity, yet their major cause is ignorance and irresponsible unhealthy decisions, day after day. The famous cartoon caption seems applicable: "We have found the enemy, and he is US!" Drivers who indulge their lifestyle desires for speed and the excitement of weaving in and out of slower vehicles attract prompt justice from the police. Reflections Could the highway authorities ensure a safe and efficient system in spite of an ignorant and irresponsible driver? Hardly - this driver would have to be removed from the system promptly. Equally, can we afford to fund a healthcare system when the majority of the public is poorly informed about health matters and half-hearted in its health behaviour? What kind of streamlined, efficient and effective healthcare system would we have if the substantial majority of citizens were IAs in health? On the other hand, what kind of carnage and chaos would we have if most drivers' highway knowledge and behaviour were at the same level as their health information and actions? Given the benefits we enjoy from the informed and responsible behaviour of most drivers, why do we settle for less informed and responsible behaviour from citizens in the healthcare system? Citizen Engagement In both public consultation and public participation, the proponent typically initiates and manages the process, with contributions by the various publics involved. Citizen engagement, however, enables citizens to commence and take responsibility for the process. It is "A two-way learning process between citizens, their elected officials and public sector institutions in a search for common ground", according to Ms. Jocelyne Bourgon, now president of the Canadian Centre for Management Development in Ottawa (6). Citizen engagement is required to overcome the massive disconnect between citizens and government. U.S. pollster Daniel Yankelovich reports that in the early `60s, 76% of the public felt that the government could be trusted "to do the right thing most of the time"; now 76% of the public disagree with that statement (7). Similar skepticism has been found in Canadian polls (8). A Health Canada Working Group has developed a Public Involvement Framework & Guidelines, available on its website, with a substantial section on citizen engagement including its role, uses, features and differences from traditional public consultation (9). Health ministers, the health establishment and citizens have been pondering the dubious merits of user fees, a parallel private system and other ways to enable the present healthcare system to continue. But is this the right question? Instead, I suggest all three should examine the option of a campaign to develop citizens as informed and active participants in healthcare. In the process by which people adopt new ideas and practices, the fundamental first step is that they recognize a need and believe that change is possible. I believe that in the present climate of public opinion, many citizens are willing to accept the challenge to become better informed about health and take more responsibility for their own health actions. The time is right to launch this campaign, drawing on Health Canada's knowledge and experience in health education and promotion, provincial health ministries across the country and the voluntary sector. Elements for a National Program
Elements for a Community Program Communities such as Victoria, B.C., which feel the pressure of demographics with a rising proportion of seniors, may wish to test some of these approaches sooner, rather than wait for a national program to develop. The practical examples reviewed in Revitalizing Medicare may be encouraging (11). A Community Health Hotline was suggested about four years ago as a means to identify, report to authorities and, if necessary, publicize to the community when someone falls through the cracks or when gaping holes appear in the system (12). Conclusion We have been warned that simply pumping more money into Canada's current healthcare system is no solution. The current proposals to add user fees and parallel private elements do not seem to have won widespread support. After reviewing public attitudes, knowledge and behaviour, I have proposed an analysis of the various publics for healthcare according to their levels of knowledge and motivation. A review of the public management of drivers on roads suggests a radical proposal to encourage the public's knowledge of health issues and to foster personal responsibility for healthy behaviour. By creating opportunities for citizen engagement, people can work on health issues with their neighbours, health administrators and elected officials. Based on the Oregon Health Decisions model, this could result in more informed and active citizens on health issues and a more streamlined, efficient, effective and affordable healthcare system. References
Acknowledgements I appreciate comments received on an early draft from Ms. Mary Hegan of Ottawa, Ms. Chris McKnight of Victoria and Ms. Jane Armstrong of the Environics Research Group in Toronto. This paper will be presented at the annual conference of the International Association for Impact Assessment in Cartegena, Colombia, May 26 - June 1. Biog. Note Desmond M. Connor of Victoria, B.C., is an applied sociologist-anthropologist (Ph.D., Cornell University, 1963) with an international practice in public participation. During the last 30 years, he has completed over 300 projects, mostly in Canada, some in the U.S. and since 1996 in the Philippines, Costa Rica, Portugal, Panama, Australia, Europe and Chile. See www.connor.bc.ca/connor for more, including a Library. Comments Wanted Please email your comments and ideas on the above article to Des. Connor at connor@connor.bc.ca
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