After the Parliamentary Budget Officer (PBO) released the cost estimate for Bill C‑7 (medical assistance in dying), he was asked to identify federal investments in palliative care made since Canada had legalized medical assistance in dying.[i]
Palliative Care Framework and Action Plan
On 30 May 2016, Sarnia—Lambton MP Marilyn Gladu introduced Private Member’s Bill C-277, An Act providing for the development of a framework on palliative care in Canada. The bill received Royal Assent on 12 December 2017. According to the preamble, “a request for physician-assisted death cannot be truly voluntary if the option of proper palliative care is not available to alleviate a person’s suffering.” This legislation requires the Minister of Health to develop a framework for palliative care and report to Parliament within a year after the Act comes into force. The Minister must table another report on the state of palliative care in Canada within five years of tabling the framework.
The government released its framework on palliative care in Canada in December 2018.[ii] Through information request IR0554 (November 2020), the PBO received details on the cost of developing the framework, which totalled $83,000 in 2018–19. In August 2019, the government published an action plan on palliative care, in keeping with its commitment in the framework.[iii] The action plan cost $6,000 to produce in 2019–20. The framework also states that “Health Canada will establish the Office of Palliative Care (OPC) to provide high level coordination of activities going forward. The OPC will be resourced internally through existing funds within Health Canada.” The OPC has generated costs of $33,000 from 2016–17 to date.[iv]
Through the information request to Health Canada, we also learned that the government spent $38,000 in 2016–17 on outside contracts, including a survey on potential national activities to improve palliative care and the identification of provincial/territorial priorities for palliative care.
The federal government’s most significant expenditures involve funding for various projects to support palliative care. In total, the government has spent more than $13 million since 2016–17 and expects this amount to increase by the end of 2020–21, as other projects are still in development and have not been officially announced. Table 1 offers a breakdown of expenditures to date, by fiscal year.
|Framework on palliative care||83,087||83,087|
|Action plan on palliative care||6,163||6,163|
|Office of Palliative Care||2,000||3,000||11,046||9,565||7,395||33,006|
|Funded projects through grants and contributions||868,521||1,839,000||3,165,400||4,501,684||3,192,628||13,567,233|
Budget 2017, tabled in the House of Commons on 22 March 2017, announced $6 billion in funding over 10 years for home care and $5 billion over 10 years to support mental health initiatives. The purpose of this funding is to ensure “improved access to home, community and palliative care services; more support for informal caregivers; and better access to mental health support.” Budget 2017 also provided for the following expenditures over a five-year period (chapter 3, page 193):
|Home care and mental health||300||850||1,100||1,250||1,500|
In August 2017, the provinces and territories (aside from Quebec) agreed on a common statement of principles on shared health priorities.[v] Between 2017 and 2019, the federal government subsequently signed bilateral funding agreements with each province and territory.[vi] Each province and territory developed an action plan, usually appended to the bilateral agreement, that specified how the federal transfers would be used. However, only six provinces identified initiatives specific to palliative care (British Columbia, Alberta, Saskatchewan, Manitoba, New Brunswick, and Newfoundland and Labrador). According to the provinces’ bilateral agreements, the total funding for palliative care initiatives for these six provinces will be $170 million from 2017–18 to 2021–22. Table 2 shows palliative care spending as provided for in the bilateral agreements.
|Palliative and end-of-life care||4,930||11,810||12,800||12,800||17,710||60,050|
|Enhancing access to palliative and end‑of‑life services||3,200||8,100||8,100||8,100||8,100||35,600|
|Palliative care enhancements||700||2,420||3,820||5,000||5,000||16,940|
|Hospice and palliative care services||600||2,000||3,600||6,200|
|Palliative care strategy||2,500||3,000||3,000||3,000||11,500|
|Newfoundland and Labrador|
|Home First integrated network|
|Additional clinicians for palliative/complex care||2,820||3,100||3,230||3,290||3,770||16,210|
|Enhanced access to palliative/complex/dementia care||3,940||4,530||3,970||7,100||19,540|
|Palliative care/end-of-life improvement|
|Public awareness campaign for advanced health care planning||100||100|
|Additional hospice bed capacity||1,100||1,100||1,100||1,100||4,400|
For other provinces and territories, palliative care is generally part of broader initiatives, such as expanding access to home care in Ontario, which also includes palliative and end-of-life care at home. Unfortunately, the specific amounts allocated to palliative care are not available for these provinces and territories. Because health is a provincial jurisdiction, Health Canada does not have access to, or the authority to request, program-specific accounting. Similarly, section 79.4 of the Parliament of Canada Act entitles the PBO to access information only under the control of federal departments or Crown corporations. The companion document “Annex - Bilateral Agreements,” which can be downloaded from the PBO website, contains tables detailing the amounts allocated to all initiatives funded under the bilateral agreements by province/territory, as presented in the annexes to these agreements.
Looking at the totals of bilateral agreements by province/territory for each fiscal year, they are almost identical to the amounts announced in Budget 2017. PBO has therefore sought, through Information Request IR0554, the actual amounts disbursed by the federal government for each fiscal year. Table 3 provides this breakdown by province/territory, by fiscal year. It shows that the amounts are generally quite close to those announced in the bilateral agreements.[vii] The agreements specify that the overall envelope for each fiscal year is distributed among the provinces and territories based on the quarterly preliminary estimates of their respective populations on 1 July of the same fiscal year, published by Statistics Canada each September. This mainly explains the discrepancies between the amounts announced and those actually transferred.
|Prince Edward Island||1,228,964||3,514,879||4,592,847||5,250,098||14,586,788|
|Newfoundland and Labrador||4,382,862||12,049,798||15,262,236||17,172,073||48,866,969|
Table 3 also shows that Nunavut did not receive a transfer for 2018–19, likely due to the fact that the bilateral agreement with the federal government was not signed until March 2019. Note that 2020–21 is not yet complete and that Health Canada advised us that the November payment (the second of two annual payments) had not yet been made at the time of the information request because the annual financial statements required in sections 4.3.1(e) and 5.1.2(b) of the bilateral agreement had not yet been produced.[viii] The Northwest Territories are in the same situation. Since each payment is supposed to represent 50% of the annual total, it is possible that the actual amount paid to date for 2020–21 may only be $567,423 (half of $1,134,846) for Nunavut and $742,677 for the Northwest Territories.
The PBO identified a total federal investment of $184 million between 2016 and today, specifically for palliative care. Table 4 presents the total investment in initiatives specific to palliative care by fiscal year. As mentioned earlier, these figures underestimate the investment for two reasons. First, the salaries paid to Health Canada officials involved in developing the framework and action plan on palliative care, as well as those working for the new Office of Palliative Care, are not included in this total. Since existing resources were reallocated to these tasks, Health Canada did not include their cost in its response to our information request.
|Federal investments in palliative care||909||1,842||3,260||4,517||3,200||13,728|
|Initiatives specific to palliative care in bilateral agreements||11,650||33,070||37,180||39,260||49,380||170,540|
Second, other provinces that have not identified initiatives specific to palliative care in bilateral agreements have nevertheless likely allocated funds to expand the availability of palliative home care. Assuming that these provinces will allocate the same share of funding received for home and community care to palliative care as the provinces that identified specific initiatives (on average 16.2%[ix]), there may have been an additional investment of $306 million. Table 5 provides estimates of the amounts allocated to palliative care under this assumption.
|Prince Edward Island||133||401||435||435||604||2,008|
Although the Quebec government had promised additional palliative home care groups in 2017, it was not until December 2019 that an agreement was reached with the Fédération des médecins omnipraticiens du Québec (FMOQ).[x] As a result, the estimate presented for Quebec in Table 5 is most likely overstated for 2018–19 and 2019–20.
Lastly, all the bilateral agreements expire on 31 March 2022 (except for the Nunavut agreement, which expires on 31 March 2023) and will need to be renewed. The total of the amounts presented in the bilateral agreements corresponds to the total of $5 billion announced in the 2017 Budget for 2017–18 to 2021–22. Since the government promised in the 2017 Budget to invest $11 billion over 10 years, including $6 billion for home care and $5 billion for mental health and addictions initiatives, it can be assumed that renewing the agreements will provide an additional $3 billion for home care. Assuming that the provinces and territories still allocate 16.2% of this funding to initiatives specific to palliative care, we can expect an investment in palliative care of $485 million between 2022–23 and 2026–27.
[i] Bill C-14, An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying), was introduced on 14 April 2016 and received Royal Assent on 17 June 2016.
[iv] As stated in the palliative care framework, the OPC is to be resourced internally through existing funds within Health Canada. Therefore, all the amounts in this paragraph correspond to external costs (consultations, translation, design and printing, and so on). We do not know how many employees (full-time equivalents) worked on these initiatives, but the costs would clearly be higher if we factored in these employees’ salaries.
[v]https://www.canada.ca/en/health-canada/corporate/transparency/health-agreements/principles-shared-health-priorities.html. On 10 March 2017, the governments of Canada and Quebec agreed on an asymmetrical agreement that is separate from this statement of principles and based on an asymmetrical agreement from September 2004.
[vi] The text of each agreement is available at https://www.canada.ca/en/health-canada/corporate/transparency/health-agreements/shared-health-priorities.html.
[vii] The amounts by province/territory for 2018–19 and 2019–20 could also be validated by accessing the Public Accounts of Canada, Volume III, Section 6: Transfer payments (https://www.tpsgc-pwgsc.gc.ca/recgen/cpc-pac/index-eng.html)
[viii] To receive annual funding, provinces must also work with the Canadian Institute for Health Information (CIHI), which has been mandated to develop pan-Canadian indicators to measure progress on improving access to these areas of health care. CIHI reports are available at https://www.cihi.ca/en/shared-health-priorities.
[ix] The average is weighted by the total amount received for home and community care.
[x] Radio-Canada (December 4, 2019). “Québec et les omnipraticiens s’entendent sur les soins palliatifs à domicile” https://ici.radio-canada.ca/nouvelle/1417448/quebec-et-les-omnipraticiens-sentendent-sur-les-soins-palliatifs-a-domicile.