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Public drug plans in Canada continue to grapple with public sector pharmaceutical drug spending growth that exceeds revenue growth. Public drug spending is expected to account for 9% of public sector healthcare expenditures in 2010 (approximately 12.1 billion dollars) (CIHI, 2010).

This issue persists despite the introduction over the last two decades of various drug reimbursement policies to control cost, including beneficiary cost sharing, mandatory generic drug substitution as well as prior authorization and other forms of utilization review. Other approaches are needed.

Furthermore, some of these policies may have unintended consequences on patient health, access to drugs for those without comprehensive drug coverage, pharmaceutical innovation, the timely market entry of generic drugs, the provision of professional pharmacy services and spending on drugs.

Bulk purchasing and reference pricing policy have numerous advantages for all Canadians compared to the practice of best price policies by some provinces.

actual cost savings can only be obtained in integrated systems of care that enable trade-offs between lower-cost homecare services and more costly long-term care facilities

Over a 10-year period from the mid-1980s to the mid-1990s, British Columbia had an integrated system that allowed it to restrain the growth of longterm care beds and invest new money into home care, which resulted, after 10 years, in estimated annual cost avoidance of about $150 million.

it is often non-professional supportive care that allows people to continue to function independently

A B.C. study found that people who had been evaluated by nurse assessors as needing homemaking services due to their frailty, and whose home care was discontinued, cost the system considerably more, three years later, than people in similar communities with similar conditions who had been able to maintain a modest level of home-support services over the same period of time.

Howard Waldner, president and CEO of the Vancouver Island Health Authority

Hospitals are experimenting with “virtual” wards that provide follow-up care at home for patients with chronic medical conditions to lessen their chances of being re-admitted

Pharmaceutical spending has grown rapidly over the past decade, and as a nation we have no coherent plan in place for getting sufficient value for the money we spend. Ontario has made substantial progress in reducing the costs of generic drugs, but national progress in this area will require co-operation among the provinces.

preferred provider networks, mandatory generic substitution, agreements between pharmacies and insurers (which stipulate that a pharmacy will lower its costs for the clients of a certain insurer if that insurer directs its clients to the pharmacy in question), and step therapy (which requires plan members to try certain drugs first before switching to more costly medications). Add to that the new high-cost drug pooling agreement for fully insured plans—which shelters firms from the full expense of any high-cost and recurring drug claims—and it’s clear that the pace of change in the insurance market has been unprecedented.

The overall mission of the PMPRB needs to change so that it strives for the lowest possible prescription drug prices for all Canadians.

one that recognizes and rewards truly breakthrough drugs

Stephen Frank is vice-president, policy development and health, with the Canadian Life and Health Insurance Association. sfrank@clhia.ca

To make aging at home a reality for all Canadians, we must redesign the delivery of home care to make it more accessible, accountable and affordable.

As government funding continues to decline, unpaid caregivers — typically a spouse or child — are having to fill the gap or pay out of pocket to hire care privately. In 2007, approximately 3.1 million Canadians, largely women between the ages of 45–64 years old (44%) (StatsCan 2012), were estimated to act as an informal caregiver to their loved ones, providing over 1.5 billion hours of care annually.

These caregivers provide 10 times the number of care hours by formal services, which is not only taxing on their personal well-being and their relationship with their recipient, but also on Canada’s economy — the cost to businesses from absenteeism and turnover related to unpaid care was estimated to be $1.28 billion in 2007.

The Caring Economy is made up of for-profit marketplaces that serve the needs of others. Like the Sharing Economy, it is a marketplace that empowers neighbours to care for neighbours— removing the need for corporations to intervene. Through the latest mobile technology, businesses in the caring economy connect the supply of care to the demand for care.

In the Caring Economy, there are two key end users: the demand side that needs to hire care and are willing to pay and the supply side that has time and is looking to help. Demand side users can build their own personalized team of care providers, communicate directly within the platform, and pay on demand via mobile payments — a seamless, convenient and transparent process. This is made possible through a peer-to-peer marketplace that uses mobile technology to efficiently manage the relationships between paid care-workers to primary caregivers and their loved ones — on demand. Simply put, it is Uber for home care.

At its core, this model redesigns how care is delivered to make ‘aging in place’ a reality. The model’s objective is threefold — to help seniors age with dignity, to unburden their family caregivers, and to turn compassionate people and Personal Support Workers (PSWs) into ‘micro-entrepreneurs’ — providing them with an opportunity to earn a 20–30% higher wage- a win, win, win.

The Uplift® smartphone platform delivers on-demand home care services — at the touch of a button. As a company, we are laser focused on harnessing the latest mobile technology and analytical problem solving to deliver a superior user experience that fulfills the aging population’s demand for higher quality care. We are setting the new standard.Our app is an affordable solution to expensive agency fees. We offer 30–50% lower fees than private agencies. We are also an innovative substitute to long-term care.As an organization, we are devoted to making a positive impact in the world. Moreover, we are a pioneer of the ‘caring economy’ — where neighbours can care for neighbours and caregivers are empowered.

And what can be said of Mr. Harper's contempt for Canadian scientists? Under his rule, federal expenditures on university research have put Canada near the top of the global rankings for publicly funded research and development. The Conservative Leader clearly believes the state has no place in basic research. Why else would his government give the Canadian Institutes of Health Research $1-billion a year, or provide the Canadian Foundation for Innovation with $1.3-billion to support research infrastructure at postsecondary institutions and hospitals?

Mr. Harper's war on state-funded science includes the $243-million he has promised to fund Canada's participation in the Thirty Meter Telescope project; the extra $45-million awarded this year to the TRIUMF cyclotron particle accelerator; the $105-million committed to enable scientists to collaborate on research through the CANARIE cloud-computing network; and the $15-million promised to the Council of Canadian Academies to conduct "science-based assessments." The GM and Chrysler bailouts set the tone for the Harper government's hard line on corporate welfare. It has been a dry well ever since. Most recently, this unyielding insensitivity toward the pleas of manufacturers has manifested itself in a $300-million loan to Pratt & Whitney Canada to develop jet engines and a $60-million loan to Toyota to upgrade two auto plants in Ontario.

The Harper Tories have shown their disdain toward the Liberal fetish for picking winners by boosting (after renaming) a smorgasbord of industrial policy slush funds, including the $1-billion Strategic Aerospace and Defence Initiative and the Automotive Innovation Fund. The latter's $250-million annual kitty was increased to $500-million a year for two years in the 2014 budget. The Harper government's clean-tech fund, Sustainable Development Technology Canada, has doled out $740-million so far, with hundreds of millions more still to go out the door. No wonder the Liberals and New Democrats have been calling for the state to re-engage with business to boost Canadian innovation. After all, the Tories abdicated their responsibility in this area by conducting the most comprehensive review of federal support for private-sector research in decades and implementing the main recommendations of a 2011 expert panel's report on the matter. The Scientific Research and Experimental Development Tax Credit, which cost $3.5-billion annually and had been subject to much abuse, was scaled back by about $500million - with most of the savings plowed into direct grants to businesses, just as the experts ordered.

It's debatable whether any of this largesse has made Canada's economy more competitive or innovative. No amount of state support can compensate for a lack of vision or guts among businesses. It's not for a lack of trying by Ottawa that innovation policies that seem to work elsewhere aren't replicable here. The state can go only so far to substitute for the private sector's listlessness. To wit, firms in the oil patch are reacting to tough times by cutting R&D, which is exactly the opposite of what they should be doing right now. They should know only innovation can save them.

Now, Liberal Leader Justin Trudeau is vowing to "invest in Canada" by doubling infrastructure spending, while NDP Leader Thomas Mulcair promises to be a "champion" of manufacturing (subsidies). They have big shoes to fill. Both would be hard-pressed to outdo Mr. Harper, who, if you haven't gleaned by now, has turned out to be as much of a meddler as any Liberal who preceded him.

Doing so requires the business community to engage with the Department of Foreign Affairs, Trade and Development and EDC in the effective design and implementation of the government's new initiative. Done well, this initiative could leverage Canada's strengths in finance, natural resources, infrastructure construction and engineering to catalyze private investment that will accelerate the global push toward the United Nations' Sustainable Development Goals (SDGs). The initiative could also build on the skills and experience of Canada's large immigrant communities to strengthen trade and investment links with emerging and frontier markets - countries that are now responsible for the lion's share of global growth, but where Canada's business presence is tiny.

Senior fellow at the Jeanne Sauve Foundation and visiting scholar at Massey College in the University of Toronto. He tweets at @BrettEHouse. In its 2015 Economic Action Plan, the federal government announced its intention to create a $300-million, five-year "development finance initiative" to partner with private capital to create growth and jobs in low-income countries. The budget document anticipates that this initiative - to be located within an expanded Export Development Canada (EDC) - will provide a mix of financing, technical assistance and business advisory services to enterprises operating in line with the government's international assistance priorities.

As outlined in a submission to Parliament last summer by the Centre for International Governance Innovation and Engineers Without Borders, the experiences of Canada's G7 counterparts offer some important lessons for Ottawa's initiative. An effective initiative should address market failures; that is, it should fill gaps in the financial system that prevent good projects, sound businesses and effective entrepreneurs from obtaining the financing they need on reasonable terms. A classic example would be the situation of new immigrant entrepreneurs: They know their former countries well, they are ideally placed to build links between Canada and their birthplaces, but their lack of Canadian credit history makes it difficult for them to gain access to affordable borrowing to grow their businesses. Ottawa's new initiative will need to be empowered with a full range of financial tools - a variety of lending instruments, a mandate to take equity positions, the ability to write guarantees, the option to underwrite insurance products - that it can tune flexibly to take projects from their early days to full bankability.

It needs to be risk-loving and clear-eyed about the fact that some projects will fail, and maintain a long horizon on investments that typically take many years to pay out returns and development impact. This new development finance initiative should also embrace open competition. The most successful DFIs work with the most effective firms on the most innovative projects.

They're not limited to working with their own nationals. Both Canada and developing countries will benefit most if this initiative is made accessible to the best people, ideas and execution. Finally, Canada's new development finance initiative needs to take poverty reduction just as seriously as profit generation. Most other DFIs do this imperfectly, at best; some don't even monitor the impact of their projects on development. This makes no sense. Development is good for business and business can be good for development.

Five years from now, development gains will be just as important as profits in making the case for renewed funding of this initiative. All these lessons need be adapted to both the needs of Canadian business and Canada's specific development objectives. The Canadian Chamber of Commerce and Canadian Council of Chief Executives have both been important supporters of this project. Now it's time for the businesses that stand to benefit directly from this initiative to get involved ensuring its success.

Traditional medicine is a system of medicine in the same way that Western medicine is a system, in the same way naturopathic medicine is a system,” says Dr. Karen Hill, who shares a practice with traditional healer Elva Jamieson on the Six Nations of the Grand River First Nation in Ohsweken, Ont. “Because it doesn’t look the same, I think physicians don’t know how to receive it.”

Hill, who is Mohawk, believes a clash of cultures influenced the decision of doctors at the McMaster Children’s Hospital in Hamilton, Ont., to ask Judge Gethin Edward of the Ontario Court of Justice to compel cancer treatment for J.J, an 11-year-old Mohawk girl who has acute lymphoblastic leukemia. Although Hill neither confirmed nor denied that she and Jamieson are treating J.J., Hill did testify in the case. Edward ruled in November 2014 that J.J.’s mother, the girl’s substitute decision-maker, had a constitutionally guaranteed right to practise traditional medicine.

On Jan. 19, 2015, Makayla Sault, another 11-year-old Aboriginal girl with leukemia, died following a stroke. Makayla and her family, who are from the neighbouring Mississaugas of the New Credit First Nation, had also stopped chemotherapy at McMaster. Makayla’s death has drawn international attention to the issue of consent to treatment and whether Aboriginal rights may potentially clash with a child’s best interests and right to life.

Both cases have also raised the question of how doctors should respond to an Aboriginal patient’s desire to pursue traditional or other types of medicine over Western medical treatment. “The big message is that this is not just about medical choice,” Hill told CMAJ. “This is about indigenous people reclaiming their wholeness as people. This isn’t about religion; it isn’t about choice. It’s about being who we are.”

Choosing one type of treatment over the other is not the only option, say Hill and Dr. Veronica McKinney, a Cree/Métis woman who is on the executive of the Indigenous Physicians Association of Canada.

“More and more people are coming to understand that you can have a blend (of treatments),” says McKinney, who is the director of Northern Medical Services at the University of Saskatchewan. “I have a number of patients where this is the case, and I support that.”

In J.J.’s case, McMaster made an effort to permit the family to pursue its traditional practices, says Daphne Jarvis, McMaster’s lawyer. “There was a ceremony that took place in the hospital that the family arranged and they seemed very appreciative of that,” she told CMAJ. “With respect to the use of traditional medicines, I think the caveat was: ‘as long as it doesn’t interfere with the chemotherapy’ — so that was perceived to be hierarchical, which it wasn’t intended to be.”

Hill, who graduated from McMaster University medical school, and Jamieson, who apprenticed with her mother on Six Nations, often work together with patients to plan a combination of traditional and Western medical treatment.

Practitioners need a trusting relationship with their patients that includes self-reflection, respect for other world views, and reciprocity that acknowledges the patient’s contribution to healing, says McKinney. “When you are the one making all the decisions aside from the patient, you’re going off-track. It doesn’t matter whether we’re talking cancer or high blood pressure ... that completely does not match patient-centred care.”

There are few medical institutions in Canada, McKinney says, that support the positive contributions of traditional medicine, which includes plant-based medicines, ritual and ceremonies, alongside efforts to establish mental, spiritual, emotional and physical balance.

Doctors continue to have a responsibility to report similar situations to child welfare authorities, says Jarvis. Those authorities should conduct sufficient investigation to satisfy themselves that families are pursuing a sincerely held practice of indigenous medicine, she adds. It’s up to child welfare authorities, not doctors, to determine how sincerely held are the beliefs in traditional medicine, she cautions.

It was clear during the hearing that J.J’s mother is a traditional Mohawk woman accessing indigenous medicines within the Six Nations community, Jarvis says. She calls media reports about the alternative treatment the family was pursuing at the Hippocrates Health Institute in Florida, “a red herring.” J.J.’s care in Florida was in addition to the traditional treatment she was getting on Six Nations, not instead of it, Jarvis says. Hill also visited the institute to help re-establish a connection to plant-based food, which is an important part of traditional healing.

Indigenous physicians can bridge the gap in understanding between the traditional and Western medical systems, says Hill. She hopes to help design a protocol for physicians about beginning that dialogue with patients and traditional healers.

Hill understands the angst both Makayla and J.J.’s cases have caused. But she hopes the medical community will understand that Makayla’s choice was about more than just medical treatment.

“It is about living and being Indigenous people, trusting our own medicines in the way we did for centuries before Western medicine. Behaving as indigenous people is what the mainstream finds difficult to understand and what the medical community needs to start working out in relationship with our people.”