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October 31, 2001
1. Introduction
The United Nations Convention on the Rights of the Child (1989) calls upon all of its signatories – including Canada – to first and foremost, act in the "best interests of the child[1]" in all that we do. This imperative necessitates that supporting healthy child development in all of its facets be included as a central tenet of the Romanow Commission's efforts to rebuild and reshape our health care system.
Ensuring healthy child development is a fundamental step in building the health of a nation. Failure to adequately support our children's health is akin to building a home without a proper foundation: the structure may appear sound at first, but eventually, exposure to various elements will begin to compromise the integrity of individual components, leaving the entire structure weakened, and, ultimately, unsound.
The Canadian Institute of Child Health (CICH) understands healthy child development to be much more than the absence of disease. Rather, it is the sum of a broad range of determinants, including:
Since its inception 25 years ago, CICH has worked alongside parents, caregivers, doctors, nurses, social workers, teachers and many others to ensure that children are provided with the appropriate circumstances in which to thrive. The Institute calls upon the federal government of Canada to take a leadership role in ensuring that all of our nation's children are given the necessary opportunities to reach their full developmental potential.
Childhood represents a highly sensitive developmental period that is unique to each child. A missed opportunity to support children's health at any stage in this cycle may reverberate negatively across the life span. Scientific research has demonstrated that early detection of developmental problems or challenges coupled with a swift, appropriate response are critical to a healthy childhood trajectory (Tipper and Avard, 1999). Every child is unique; and, every child has the right to grow, learn and play to the best of his/her ability.
To best meet these needs, CICH urges the Commission to consider the following recommendations:
2. Canadian Institute of Child Health
For 25 years, the Canadian Institute of Child Health (CICH) has acted as a dedicated voice for children, improving their health and well-being. CICH works to ensure that this goal is met through its many publications and resources for parents and health professionals. The Institute is a leader in identifying evolving health issues, advocacy, policy development and promotion, and research as it relates to children and their families.
Our Mission Statement:
Dedicated to promoting and protecting the health, well-being and rights of children and youth through monitoring, education and advocacy.
Our Objectives:
The role of CICH in child and family heath involves working with governments to make sure the right kind of policies are developed; working with professionals and educators to equip them with the best in research and programs; and reaching out to families to help everyone with the crucial task of nurturing, protecting, educating and empowering our children. CICH is determined to ensure all of Canada's children the best possible future by making them a top priority.
The Canadian Institute of Child Health is a national, charitable organization with a volunteer Board of Directors, top Canadian advisors in the child health field, and a professional staff.
CICH is a member of both HEAL, the Health Action Lobby, a national coalition of health organizations and the Health Charities Council of Canada, a coalition of health charities. We support the recommendations presented in both submissions, especially the need for a comprehensive publicly funded health system addressing the continuum of care, the need for clarification through legislation of the Canada Health Act, an immediate need of human resource planning and the importance of the role of the voluntary sector to Canadians in the delivery of services that address the health determinants. Of special concern is the impact of waiting lists and user fees on families with young children who require developmental diagnosis and services for speech, hearing, etc. at a sensitive time with life long consequences.
This submission is to outline the specific needs of children, youth and their families in Canada.
3. Valuing Our Children
According to traditional health indicators, Canadian children can count themselves among the "healthiest" children in the world. To date, Canada's health care system has done a relatively effective job in supporting the healthy development of children in Canada. Unfortunately, our country's capacity to continue to meet these needs is being seriously threatened. Over the past 20 years, Canada has posted a disturbing decline in our public sector expenditure on healthcare in comparison to other OECD nations. In 1984, we ranked 15th out of 22 industrialized countries; by 1998, this had declined to 18th out of 22 (HEAL, 2001: 5).
The severity and significance of this decline is best understood when considered in the context of a growing number of new morbidities as they relate to environmental and mental health (i.e., asthma, cancer, suicide, depression) threatening young Canadians. Of particular concern is the health profile of those young Canadians living in Aboriginal communities, those of recently immigrated visible minorities, and those who live in inner cities whose health is being severely compromised by factors such as poverty and violence. Equally compelling are the stories of courageous families attempting to help and encourage their children and youth with disabilities without adequate support services. These realities represent some of the new challenges facing our health services system as it struggles to meet the changing needs of Canadian children amid severe financial cutbacks and critical human resource shrinkages.
It is clear that Canadians want and need more for their children. Research conducted by the Canadian Policy Research Network has demonstrated that, across the country, Canadians feel that:
Perhaps the time has never been more appropriate for the federal government to refocus its commitment to children's health and develop a more robust, family and child-centred service-delivery model that responds directly to need in the most appropriate manner – a model that reaches out to children and families where they live, learn and play, and that focuses attention on prevention and promotion, not simply on reparation.
4. Sustainability
4.1 Medical Necessity
Ultimately, contemporary health services have been designed to restore and to promote health. In particular, paediatricians have had tremendous success in improving the overall health of Canada's youngest citizens (CPS, 2001: 4). Long waiting lists and collapsing services reflect that the ability of our current system to continue to meet the health needs of Canadian children is in serious jeopardy.
In their analysis of the current state of health human resources in Canada, Watters and Robeson (1999) point to an alarming trend in the depletion of overall physician numbers that will result in a shortage within the next 5-10 years (p.11). Family physicians comprise 50% of the overall medical workforce and as many as 80% of them report that they are engaged in child health care (Ibid: 19). Clearly, overall medical workforce shortages will have a significant impact on primary medical care for children and youth. More specifically, findings from a recent national survey conducted by the Canadian Paediatric Society (CPS), conclude that "health care for Canada's children and youth, particularly those living in remote and rural areas, is at risk of deteriorating due to a pending shortage of paediatricians." (CPS, 2001: 3)
The CPS survey alerts us to a looming crisis in the Canadian paediatric work force. Approximately 40% of those paediatricians who responded to the survey claimed that they will retire by 2010. With fewer and fewer paediatric residents entering training programs every year, we are clearly heading towards a supply crisis. This shortage will be most acutely felt in rural and remote communities, where access to high quality medical care for children and their families is already limited. According to the CPS, over 80% of Canadian paediatricians currently work in towns with a population of more than 100,000 (Ibid: 3).
Equally troubling is the growing paucity of young doctors entering paediatric sub-specialties. Watters and Robeson (1999) point to a shortage of neonatologists and neonatal nurses and long waiting lists for paediatric elective surgery (p.20). In the search for effective cutbacks, it would appear that many hospitals are targeting low-volume/high-cost services. Many paediatric subspecialty services fall into this category. However, because of the high level of interdependence among tertiary subspecialty services, cut backs in one subspecialty has the potential of radically reducing tertiary services for infants and children in the regions affected.
Financial cut backs are also having the effect of limiting the number of births that any given hospital can assist with, leaving women and their families scrambling to find appropriate care and support. Birth has often been described as "potentially the most hazardous journey taken in life". Without adequate prenatal, perinatal and postnatal care, mortality and long-term neuromotor and respiratory morbidities will ensue.
Experience in some centres, for example London Ontario, has shown that collaborative integration of midwives and specially trained neonatal nurse practitioners can minimize the effects of physician shortages. Examples also exist of effective nurse-run antepartum care clinics in other countries, including Scotland, Denmark and the U.S.
4.2 Health Service Workers
In addition to medical doctors, a broad range of health service workers play a critical role in supporting the healthy development of children in Canada, including: nurses, nurse practitioners, public health workers/nurses, nutritionists, physical and occupational therapists, speech-language pathologists, social workers, etc. For many families, access to one or more of these professionals is critical to a child's health and well-being. Unfortunately, with the exception of nurses and clinical nurse specialists, there exists very little literature or data about the size of these health disciplines or the specific role that they play in supporting child health.
With respect to the nursing profession, the future is similarly bleak. In 1997, the Canadian Nurses Association predicted a severe nursing shortage within the next decade, due to declining recruitment, retention and an accelerating rate of retirement (Watters And Robeson, 1999: 14). This forecast is of particular relevance to the ongoing delivery of health services to children and their families. Nurses work with children and youth in a variety of settings: community health, schools, family practice, paediatric offices and clinics, paediatric hospitals, maternal-newborn care settings and intensive care units. Not surprisingly, it is often said that nurses are really the front line workers in the delivery of health services to children and their families: identifying issues, responding to concerns, and supporting individuals. Clearly, any further reduction in the numbers of nurses – specifically those with specialized paediatric training – will also have a seriously negative impact on Canada's ability to best meet the developmental needs of our children.
4.3 Home Care Services
Paediatric home care, although on the rise, is a relatively new topic in the home care literature. The research, however, does point to the disturbing fact that children in need of home care remain underserved (CHCHRS, 2001: 21). This deficiency may be partially explained by the fact that paediatric home care is very different from home care for adults. Rather than focus on individual capacity building, paediatric care aims to teach the family or caregiver(s) ways to provide appropriate care for the child.
Families, therefore, are a critical factor in determining the success of home care services for children. Unfortunately, our health system is not appropriately equipped to offer families the type of support and respite that they may need to continue to care for their children in the home. Failure to meet the needs of children and families in the home may result in an increased burden on the hospital-based service delivery system and on the family.
A recent development in the field of home care is the delivery of specialized paediatric care in the home (e.g., low birth weight neonatals and children with cancer). As a result, only very sick children are remaining in hospitals. In some cases, the care needs of children at home are quite complex and may require the support of a number of specialists. Such specialized services, however, are typically based in urban areas, putting at risk families and children who do not have easy access to the support they need (Ibid: 21).
Without considerable new investment in home care by governments, family caregivers will provide more "unpaid' care to their family members, and some children will simply go without the services and support they need. In the end, "good" home care has the potential to be both cost-effective and empowering for everyone involved.
5. Cost drivers
Compounding the human resource strains upon the system are a number of outstanding unmet children's health needs. Left unmet, these issues will continue to deny Canadian children their right to reach their developmental potential, thereby robbing our nation of its future potential development. What we don't pay for now, we will pay for later.
5.1 Child Poverty
Research has made clear the relationship between poverty and population health: the lower the income, the poorer the health. A low level of family income is associated with a higher rate of low birth weight and potentially, with associated adverse effects such as chronic illness, developmental delays and disabilities. Boys from low income families have a substantially higher injury death rate than their peers from higher income families. Children living in poverty are also at a substantially higher risk for dying in a fire or a homicide, of exhibiting symptoms of hyperactivity, conduct disorder and emotional problems, and to engage in delinquent behaviour (CICH, 2000: 178-179).
With an estimated 20% of all Canadian children living in poverty (CICH, 2000: 178), we are facing a growing population of young people at risk of failing to reach their developmental potential. Clearly, living in lower income families can undermine the health and well-being of children in ways that have profound and lasting consequences.
5.2 Aboriginal Children
Aboriginal children and children living in inner-cities, in particular, are among those at greatest risk of experiencing the negative health outcomes associated with poverty and lack of access to appropriate support services. In general, the overall health status of Canada's Aboriginal population ranks below the national standard for all other populations (CICH, 2000: 145). In particular, Aboriginal children are more likely than non-Aboriginal children to live in substandard housing; Aboriginal children are slightly more likely than non-Aboriginal children to have a disability; Aboriginal infants are more than twice as likely as their non-Aboriginal peers to suffer from Sudden Infant Death Syndrome; and, among Aboriginal youth aged 15-24, the suicide rate among males is more than 5 times that of male national youth. For female Aboriginal youth, the rate is almost 8 times that of female national youth (CICH, 2000).
Without question, Canada is failing to meet the needs of Aboriginal children and their families, and, in so doing, failing to fulfill our obligations under the Convention on the Rights of the Child to act in the "best interests of the child".
5.3 Environmental Contaminants
Many factors determine whether a child is born healthy and stays healthy into adulthood. The environment is a critical, yet rather unconventional factor that must be considered. As a determinant of health, the environment is concerned with well-being and quality of life, as well as death and disease. While a toxic exposure during critical growth stages can cause permanent damage manifesting as a specific disease, involuntary, chronic low-level exposures are more likely to cause subtle, yet potentially serious and lasting health effects.
In this context, children must not be seen just as small adults, but as a population with heightened vulnerability to a variety of exposures as a consequence of their developmental, behavioural and physiological characteristics. The developing body systems of the child, particularly tissues and organs, are more vulnerable to environmental toxicants. Organ development begins during early fetal life and continues into adolescence. Brain development is of special significance because it is maximal in fetal life and early childhood, and in most aspects is a "one time" event.
Children exposed in utero or in early life to high level of pesticides, persistent organic pollutants, heavy metals and other chemicals may be at risk of endocrine disturbances, stunted growth, mental disability and other neurobehavioural and developmental effects, and allergic and atopic disorders. Children who live in poverty typically live in the most polluted parts of the community, thereby increasing their risk of exposure to environmental contaminants.
In addition to developmental and physiological differences, children's behavioural tendencies, such as playing closer to the ground and more hand-to-mouth activities, often place them at higher risk to certain environmental hazards than adults. Failure to address issues of environmental degradation, contamination, and toxic exposure as they relate to children will result in continually growing rates of childhood mortality and morbidity.
5.4 Disability
A condition that persists over time and that limits the activities of a person is considered a disability. According to the 1996-97 National Population Health Survey (NPHS), approximately 7.7% of children between birth and 19 years of age (or about 500,000 children and youth) had an activity limitation (CICH, 2000: 229). Within this population is a smaller group of children with complex care needs. In the absence of adequate services and resources, caring for a child or youth with a disability can negatively impact on the well-being of the whole family. There is an urgent need for more data on the need for and availability of supports for families, including enhanced respite care.
Similarly, in the absence of appropriate services and resources, children with Learning Disabilities are particularly vulnerable to a wide range of short term and long term negative outcomes; they are more likely to drop out of school; may be less able to effectively distinguish between acceptable or unacceptable behaviour; engage in risky or criminal behaviour, and feel alienated and unhappy (CICH, 2000: 231). Adverse long term outcomes include reduced earning capacity and increased criminality.
Advances in medicine and technology have resulted in markedly increased survival of children who experience cancer, congenital anomalies, metabolic disorders, unintentional injuries and preterm birth. While the majority of children so affected will these days lead healthy and productive lives, many have need for on-going care and services in order to achieve this normalcy. Others experience chronic illness that requires continuing care. The increased need for continuing care and the growing number of successes in this aspect of medical care have exacerbated the shortage of paediatric medical and surgical subspecialists, especially trained nurses, and others such as therapists, technicians and social workers.
5.5 Mental Health
Mental illness is often termed the "new morbidity" for children. Mental health problems cut across all income lines and have the potential to negatively effect children of all ages. Although the majority of children indicate prosocial behaviour, parental acceptance and positive peer relations, a number of problem areas exist. According to parent reports, 1 in 10 children aged 4-11 exhibit behaviour consistent with a hyperactivity disorder, conduct disorder or emotional disorder. Higher rates were reported for boys than girls (CICH, 2000). Approximately 1 in 5 children aged 4-11 have some form of behavioural disturbance meriting clinical care if such services were available (Ibid., 2000). Although children in lower income families are at higher risk of having mental health problems, more children with problems will come from the larger low risk population of children because of its size. (CICH: 2000:196).
In the case of older children, the prevalence of depressive disorder is disturbingly high, particularly among female youth aged 15 to 19 years. Depressed youth are more likely to contemplate or commit suicide than their non-depressed peers (CICH, 2000). Access to appropriate, universal mental health services is critical to the long-term well-being of all children. Unfortunately, access is not what many of them will get. Accessing mental health services in this country is confounded by a critical shortage of trained professionals available to meet the needs of children and youth with mental health and behavioural disorders (Watters and Robeson, 1999: 20). Waiting lists of 2 years are not uncommon. For adolescents, attempted suicide may be the only means of having their need for urgent care recognized. Services required are both universal, such as school-based mental and social health services, and targeted specialist clinical services.
5.6 Changing Lifestyles
Adolescence is a time of tremendous change and exploration. For some teens, this is also a stage in their development when they find themselves in a high-risk health category. Certain risky behaviours, such as sexual activity, smoking and drug use, emerge as problems during the school age years. Early sexual activity is often "unprotected", placing participants at risk of pregnancy or of contracting a sexually transmitted disease. In fact, pregnancy is the leading cause of hospitalization for female youth between the ages of 10-19; for males the leading cause is injury (CICH, 2000: 113). Approximately as many teens smoke cannabis as smoke cigarettes (CICH, 2000: 81).
Certain populations of youth, such as youth on the street and sexually exploited youth, are at extreme risk for unhappiness, injury and illness. This group of young adults reported higher levels of mental illness and many – 22% of males and 46% of females – indicated that they had attempted suicide(CICH, 2000: 130). Yet we know that comprehensive and youth friendly services can make a difference, such as youth focussed contraception clinics in reducing teen pregnancy rates. Youth focussed services address multiple indicators of health in the broadest sense, such as housing, income, employment, nutrition and mental health.
5.7 Changing Demographics
Clearly, young Canadians face a variety of health challenges throughout their developmental cycle that may have a lasting impact on their future well-being. For this reason, the Canadian Institute of Child Health encourages the Commission to base its recommendations on factors other than simple population estimates. Although the population of children and youth is becoming an increasingly smaller proportion of the Canadian population, the absolute number of children and youth will increase by about 400,000 between 1996-2016 (Watters and Robeson, 1999: 8).
During this same time, the proportion of seniors is expected to increase from 12 to 16%. Past experience has shown that the temptation will be to allocate health resources on a traditional provider-to-population basis. Clearly, young Canadians face a variety of health challenges throughout their developmental cycle which may have a lasting impact on their future well-being. For this reason, the Canadian Institute of Child Health encourages the Commission to base its recommendations on factors other than simple population estimates. To do so would be to ignore the vitally significant time sensitive nature of childhood development and place in jeopardy the future health of our nation and its children.
6. Managing Change
6.1 Sustaining a Systemic Approach
In many ways adult health is determined by a society's response to the health needs and entitlements of its children. CICH believes that a more appropriate way of supporting good child health would be to develop a needs-based system that adjusts to accommodate changing requirements. Meeting the varied needs of children and their families requires that we move beyond a hospital-based system towards a more integrated model of service delivery capable of providing quality, cost-effective health services that respond to the ever changing circumstances of children's lives.
It is essential that a system that is sensitive to the full life-cycle of childhood be adopted, not one merely responsive to the first six years, which are now receiving increased attention. The system should serve a child and family's needs in the most appropriate setting, be it school, church, community centre, friendship centre, hospital or doctor's office. And, it must be able to reach across economic, linguistic and cultural boundaries and help to build individual and community capacity. It is a system that would recognize and support the many partners involved in building the health of a nation and its children.
This system must be more than a treatment model. To be effective, it must incorporate a profound commitment to health promotion and the prevention of illness.
6.2 Working Together
Building a better system to support healthy child development will require a great deal of interdisciplinary as well as intersectoral planning, involving all levels of government, service agencies, education, professional associations, unions and regulatory bodies on an ongoing basis. While this task seems daunting, CICH asserts that this is the only way to develop knowledge of "the right mix and the right distribution of health care personnel who provide timely and appropriate service" (Watters and Robeson, 1999: 23).
6.3 Service Delivery Challenges
As has already been mentioned, geography plays a key role in determining access to child health services. Canadians living in remote or rural locations are less likely to receive the services they need than their urban dwelling peers. Addressing this problem will require a multi-faceted approach that should include the following:
6.4 Performance Measurement
Canada's ability to meet the health needs of its youngest citizens requires a more substantive, representative system of data collection across a broad range of health indicators. This data needs to be nationally representative and internationally compatible and comparable. To develop a more integrated, responsive system of service delivery for Canada's children, we need timely health related data that address questions, such as:
The federal government has a key role to play in providing the leadership and resources necessary to ensure that we have the proper data upon which to make informed, evidence-based decisions about the delivery of child health services in this country.
7. Cooperative Relations
To create a model based on best-practices, common wisdom and mutual support, the transfer of knowledge must be supported by a proper infrastructure at the community, regional and national level, and remunerated as a legitimate function of the service delivery system. Building a successful health care system of the future will require cross-disciplinary, cross-sectoral and cross-jursidictional alliances. Bridging these gaps is no simple task. To do so will require an unprecedented degree of knowledge transfer among health care professionals, families, teachers, social workers and other critical players.
Organizations like the Canadian Institute of Child Health have a critical role to play in bringing together this diversity of interests and perspectives. Non-partisan by nature and dedicated to the promotion of health and prevention of illness in regard to children, the Institute is in the unique position of having the capacity to bring together service providers, parents, researchers, national and community based organizations, professional associations and coalitions to explore the best ways to meet the developmental needs of Canada's children.
To this end, the voluntary sector, in general, needs the continued financial support of all levels of government if it is to continue its success in reaching out to Canadians, identifying issues, and building a common set of values.
8. Conclusion
The health and future of our nation depends on the health of our children. Canada will never meet its developmental potential if it fails to offer its youngest members every opportunity to meet theirs. The number of Canadian children living in poverty, suffering the effects of environmental degradation, experiencing poor mental health or failing to receive the proper medical care, stand as a reminder that our country has a long way to go before we can claim to be serving "the best interests of the child" in all that we do.
As has already been stated, the Canadian Institute of Child Health believes that a more appropriate way of supporting good child health would be to develop a needs-based system that adjusts to accommodate changing requirements. Meeting the varied needs of children and their families requires that we move beyond a hospital-based system towards a more integrated model of holistic health and service delivery capable of providing quality, cost-effective health services in a number of locations that best respond to the ever changing circumstances of children's lives.
Bibliography
Canadian Home Care Human Resources Study, 2001. Phase I Draft Report: Setting the Stage: What Shapes the Home Care Labour Market?. Unpublished, Canadian Association of Community Care, Ottawa.
Canadian Institute of Child Health, 2000. The Health Of Canada's Children, 3rd Edition. Ottawa
Canadian Paediatric Society (CPS), 2001. Planning a Healthy Future for Canada's Children & Youth: Report on the 1999-2000 Paediatrician Resource Planning Survey. Ottawa
Health Action Lobby (HEAL), October, 2001. Reconfiguration and Renewal: Ideas and Options for the Future of Canada's Publicly Funded Health Care System. Submission to the Royal Commission on the Future of Canada's Health Care System
King, Alan J.C., Boyce, William F., King, Matthew A., 1999. Trends in the Health of Canadian Youth. Health Canada
Stroick, Sharon M. & Jenson, Jane, 1999. What is the Best Policy Mix for Canada's Young Children?. Canadian Policy Research Networks, Study No. F-09
Tipper, J. & Avard, D., 1999. Building Better Outcomes for Canada's Children. Discussion Paper No F|06. Canadian Policy Research Networks Inc., Ottawa
Watters, Nancy E. & Robeson, Paula, 1999. Health Human Resources for the Future Health Care of Children and Youth in Canada. Canadian Institute of Child Health, Ottawa
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