Citizens' Circle for Accountability

A Citizen's Guide to Public Accountability, by Henry McCandless

I. A Breakthrough in Public Accountability in Canada

In the week of 13-16 September 2004, the Canadian provincial and territorial leaders met in Ottawa with the Prime Minister of Canada in a summit meeting on healthcare responsibilities. The constant national issue is what can and should be done to improve healthcare performance for citizens, where delivery of healthcare is largely a provincial responsibility yet funded largely from federal public tax money.

At the conclusion of the summit, the first ministers issued a joint communiqué that contained an unprecedented public commitment for provincial and territorial governments' public accountability. The communiqué is divided into responsibility sections.

(a) The section on reducing wait times states:
" Provinces and territories will report annually to their citizens on their progress in meeting their multi-year wait time targets."
But the section also states.
"The Canadian Institute for Health Information will report on progress on wait times across jurisdictions."
This is acceptable if CIHI's Canada-wide comparison reporting does not substitute for each government's own public accounting obligation per the communiqué that would use reporting standards proposed by the provincial/territorial auditor general and as audited by the auditor general for fairness and completeness. In detail, CIHI can obviously go beyond provinces and territories own reporting, but each government's public reporting to its citizens should be on its performance against the ranked expectations of the citizens of that particular province or territory.

(b) The section on the supply of health care professionals states:
"Federal, Provincial and Territorial governments agree to increase the supply of health professionals, based on their assessment of the gaps and to make their action plans public, including targets for the training, recruitment and retention of professionals by December 31, 2005. Federal, Provincial and Territorial governments will make these commitments public and regularly report on progress."
This is positive but missing is governments' obligation to publicly state number and timing standards to be met in the increase in supply.

(c) The section on primary care (timely access to family and community care through primary care) states:
"First Ministers agree to establish a best practices network to share information and find solutions to barriers to progress in primary health care reform such as scope of practice. First Ministers agree to regularly report on progress."

(d) The section on health care in the North states only that this is a challenge and a priority and that the federal and territorial governments will "jointly develop a vision for the North."

(e) the section on national pharmaceuticals strategy requires the government health ministers only to establish a Ministerial Task Force "to develop and implement the national pharmaceuticals strategy and to report on progress by June 30, 2006."

(f) the section on prevention, promotion and public health states that "...governments will set goals and targets for improving the health status of Canadians through a collaborative process with experts."

These sections are a start, but they do not mention governments' obligations to report their standards for progress, not just "targets."

Overall, however, the provinces' and territories' general commitment to account is clear from the section: "Accountability and Reporting to Citizens."

The text of this section reads:

"All governments agree to report to their residents on health system performance including the elements set out in this communiqué."
"All funding arrangements require that jurisdictions
comply with the reporting provisions of this communiqué."
"First Ministers of jurisdictions participating in the Health Council agree that the Council prepare an annual report to all Canadians, on the health status of Canadians and health outcomes. The Council will report on progress of elements set out in this communiqué."

Note two important commitments:

First, note that the accountability reporting of the provincial and territorial executive governments is to their own citizens, not to the federal government to whom premiers feel no accountability. This accountability provision in the communiqué made the terms put forward by Prime Minister Paul Martin and federal Health Minister Ujall Dosanjh unassailable. It said, "We are not asking you to account to the federal government; account to your own citizens."

Secondly, the funding condition says in effect: "No answering to your citizens for how you use federal funding, no money."

Referring again to the twin purposes of public accountability, the public answering commitment by each provincial and territorial government should produce information on healthcare performance that citizens would not otherwise have, and the fact that the performance reporting must be public can be expected to create a self-regulating influence leading governments to carry out their healthcare responsibilities more diligently.

Thus, through a single set of signatures on one day, the communiqué cleared away the often purposeful fog around governments' public answering obligations. In healthcare it is now a matter for legislators and healthcare activist organizations to ensure that the public answering obligations for healthcare performance are met.

The two conditions (provincial and territorial governments accounting to their citizens instead of the federal government, and federal funding being conditional on the accountings) were proposed by CCA in an article in the Victoria Times Colonist, published 13 September 2004 -- the opening day of the first ministers' summit. The CCA op-ed is reprinted in Issue 4 of CCA's Journal of Accountability.

The op-ed simply repeated the CCA proposal made to the Prime Minister's Office in July 2004, and again in August to the federal Deputy Minister of Health, that the citizens of each province and territory have the right to the accounting and that federal funding should be conditional on the accounting being given fully and fairly.

The Times Colonist article also proposed that Canadian provincial auditors general advise their provincial legislators on what would comprise reasonable healthcare accountability reporting by the executive governments to the legislatures, and to publicly audit the fairness and completeness of the governments' reporting.

The implications of the healthcare accountability commitment are immense across Canada, going beyond the health issue.

The provinces and territories have agreed to account publicly for the responsibility that citizens think is the most important in Canada today. It therefore follows that every important responsibility of every order of government in Canada, from local municipal councils to the federal ministers of the Crown, can be expected to carry with it the obligation of public explanation for how the responsibility is being carried out.
Legislators have the commonsense obligation to apply the healthcare accountability expectation to all other important responsibilities of governments. Public interest organizations related to these various government responsibilities can help force the public answering.

CCA will monitor and report on developments in this new set of healthcare accountability obligations, and on whether the precedent is applied to other government responsibilities.

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