Assessment of the Health System Performance in Ontario Major Cities (Canada).

• Author: Nistor, Adela

1. Introduction

   This study provides an assessment of the health system performance in the province of Ontario, Canada, and its major cities (Toronto, Mississauga, Oakville, and Brampton). It reports on the performance of health care organizations and local health systems over the years 2012-2018. The performance indicators analyzed are grouped into two categories: health status and quality of service (Ontario Ministry of Health). One of the concerns of health policies is the waiting time for health care. This study reports the status of wait times in major Ontario cities in 2018 for major surgical procedures: pediatric, cancer, orthopedic, cardiac and eye surgical procedures. Waiting times for emergency departments and diagnostic imaging are also reported. It also looks at government spending on health, the benchmark for surgical procedures, the number of doctors, the health status of the population, and rates of hospitalization and hospital admissions.

   Internationally, in 2015, health spending in Canada was 10.4% of GDP, lower than the U.S. (16.9%), France (11.1%), Germany (11.2), Sweden (11%), the Netherlands (10.7%). The OECD average of health spending was 8.9% of GDP (Canadian Institute for Health Information). There have been concerns in the media (CBC news) about the health care crisis in Ontario and the need for reform. Some of the problems faced by patients include bed shortages, lengthy wait times, and communication breakdown. According to the Globe and Mail (January 2018), during the summer of 2017, half of Ontario's hospitals were operating at or above 100% capacity, with one facility reaching 140%. The accepted international standard for hospital capacity is 85%, while if this occupancy rate exceeds 85% there is a high risk of hospital-acquired infections.

   The Canadian Institute for Health Information (CIHI) has initiated a three-year plan to work on reporting the performance of Canada's health care system. According to CIHI, many countries issue public reports on the performance of their health systems, while integrated health system performance reporting is required in Canada. This study fills the gap in public reporting of health system performance in Ontario's four major cities.

   The performance of the health system is important to be monitored, as it offers policymakers an opportunity to improve the health care, by improving the quality of decisions made by everyone involved in the health system. According to CIHI, the health system is defined as 'all activities whose primary purpose is to promote, restore, and maintain health', therefore including both health care services provided to individuals, as well as public health services and policies.

   Nowadays, demands for health services are increasing, and the current challenge is to develop sustainable policies and provide quality services to achieve the best possible health status of citizens, within the current socio-economic constraints. Therefore, issues related to health system performance and sustainability in the future should occupy a considerable space in policy discussions, and it is a major concern for decision makers at all levels of government to consider that major step of defining the problem based on assessment and then set objectives and strategies to formulate efficient and effective public policies. Governments have a key role in promoting the health of citizens through the provision of91 health care, so provincial governments across Canada should explore different models of primary health care reform and share them across jurisdictions.

2. Overview of health care services in the province of Ontario, Canada

   According to Closing the Gap Healthcare, the largest interdisciplinary service provider in Ontario, legislation regarding Canada Health Act was adopted in 1984 and sets out conditions to be followed by each province to receive federal transfer payments. The Health Act deals with how the system is financed and not how the health services should be delivered. Each province of Canada independently determines the delivery of the health care system.

   For the province of Ontario, 38.7% of tax dollars go to the Ministry of Health and Long-Term Care (MOHLTC). The MOHLTC's role is to create legislation to make Ontario's health care system work. The Ministry of Health takes the money and divides it into eight spending categories: the Ontario Health Insurance Program; Population and Public Health; Provincial Programs and Stewardship; Local Health Integration Networks (LHIN); Administration of the Ministry; Health Policy and Research; eHealth and Information Management; Information Systems. We will briefly present the background on the three largest expenditure segments of the MOHLTC in the period 2017-2018: Local Health and Integration Networks (50.88% operating expenses); Ontario Health Insurance Program (36.45% operating expenses), and Provincial Programs and Stewardship (7.43% operating expenses).

   Local Health and Integration Networks (LHINs) represent the infrastructure of Ontario's healthcare system responsible for the local planning of health services. There are 14 total LHINs in Ontario, each aligned according to population distribution. The LHINs examine the specific needs of their community and develop programs to provide appropriate care. There are four sections of the LHIN: Long-Term Care Homes, Community Support Agencies, Hospitals, and Home and Community Care.

   Part of the Ontario Health Insurance Program (OHIP) includes Ontario Health Insurance (physicians, practitioners), drug programs, and assistive devices. OHIP physicians/practitioners and clinics account for more than 14 billion dollars from the 19 billion dollars allocated to OHIP. OHIP clinics are funded directly through the Ministry of Health and include physiotherapy, x-ray, ultrasound, MRI, blood tests or other medical imaging clinics. These services can be free or for a minimal fee, just like when you see a primary care physician. These clinics bill directly to the Ministry of Health. Provincial Programs and Stewardship include Cancer Care Ontario, HIV/AIDS, Hepatitis C programs and emergency health services such as ambulances. Emergency transport services are free to Canadian citizens and are tax funded.92

3. Literature review

   According to the World Health Organization (WHO, 2008), studies on performance measurement of the health sector began as early as 250 years ago. Dr. Ernest Codman pioneered the idea of performance measurement as a tool for evaluating the quality of health care. Codman proposed a...