CIHR-IHSPR Strategic Priority Research Areas
- Primary and Community-Based Healthcare
- Access to Appropriate Care across the Continuum
- Financing, Sustainability and Governance
- Health Information
- Drug Policy
CIHR has a new 2009-2014 Strategic Plan entitled, Health Research Roadmap: Creating innovative research for better health and health care aimed at delivering on its commitment to respond to emergent healthcare and system needs. Roadmap 2009- 2014 designates four key strategic directions; particularly relevant to the mandate of CIHR-IHSPR is the direction to address health and health system research priorities. Within this direction, we are committed to supporting a high-quality, accessible and sustainable health-care system. Listening for Direction (LfD), an open forum to the opinions and guidance of decision and policy makers, is one means through which CIHR-IHSPR achieves this commitment. The process of LfD is set up to identify the important and urgent issues in the management and organization of health services delivery that would benefit from an investment in research; these issues are then integrated into certain broad theme areas. CIHR-IHSPR has built on the areas in need of research investment identified in the third round of LfD (2007) to focus on the following strategic priorities: Access to Appropriate Care across the Continuum, to which Primary and Community-Based Healthcare research is central; Financing, Sustainability and Governance; Health information and Drug Policy.
Primary and Community-Based Healthcare that is efficient and well-founded is integral to any high-performing healthcare system, and is tied to better health outcomes, greater equity, and an improved patient experience. As the "face" of the Canadian healthcare system, Primary and Community-Based Healthcare serves as the initial and most frequent point of contact for all Canadians- from infants, children, youth, and adults to the elderly. These individuals increasingly receive a diverse and comprehensive array of first-level services outside hospital settings from a range of primary and community-based healthcare providers, including prevention, prenatal care, episodic care, chronic disease management, mental health care, post-hospitalization follow-up, rehabilitation, and palliation.
Despite investments in primary healthcare over the past several years, major gaps in knowledge and the application of knowledge remain; also, systems of patient-centred, comprehensive, and coordinated Primary and Community-Based Healthcare have not yet been achieved across Canada. There is not only a demand for quality research and supporting evidence to promote new practices and policies, but there is also a need for evaluative and implementation research to address the many existing innovations that have not yet been assessed or scaled-up. In order to improve health care, policy makers, administrators and providers must have clear and persuasive evidence of effective interventions and practical solutions in the Canadian context.
The Primary and Community-Based Healthcare strategic research priority builds on CIHR-IHSPR's previous initiatives in such areas as wait times, timely access to appropriate care across the continuum, health human resources, and improved access for at-risk, vulnerable populations. Within this strategic priority, CIHR-IHSPR has identified the following key areas of interest:
- The policies and mechanisms needed to ensure that patient and community needs are at the forefront of primary and community-based healthcare delivery
- The most effective means of delivering high-quality, sustainable primary and community based healthcare (including multi-morbidity and chronic disease management) to patients, especially those at-risk populations that are also disproportionately served
- The policies and mechanisms of coordinating and integrating primary and community-based healthcare with other facets of the healthcare system as a means to improve patient experiences and outcomes
- The organizational, funding, administrative, and care delivery models, which optimize provider collaboration, roles and scopes of practice, incentives, and outcomes
- The most effective ways (including change management, which deals with providing a bridge from evidence and into policy, implementation, and methods of knowledge translation) to drive best practices, evidence and innovation into practice at all levels, from care delivery to policy, of primary and community-based healthcare
Access to Appropriate Care across the Continuum builds on the Primary and Community-Based Healthcare research priority area, as a distinct research focus to address issues related to access to quality care beyond primary and community-based healthcare. This strategic priority has developed in response to the recognition that Canadians expect access to quality healthcare services when and where they need them, and that Canadians increasingly receive care outside of hospitals within a range of community and other settings, as well as from various healthcare providers who may or may not belong to Medicare.
Evolving from previous initiatives in areas such as timely availability of care, health human resources, and improved access for at-risk, vulnerable populations, CIHR-IHSPR acknowledges that Canadians want a sustainable healthcare system that provides access to appropriate healthcare services and treatments in good time. Canadians expect health services and treatments, based on the best and latest evidence, that improve their health and quality of life. Ensuring their constituents have access to timely, appropriate and effective health care is a challenge for federal, provincial and territorial governments alike. For the most part, policy makers are aware of the problems that exist and where the gaps in the system lie; they need, however, evidence-informed approaches and implementation strategies to improve access to, and the quality of, proper care across the continuum. This includes productive approaches to health service planning and management, training of health human resources, improving healthcare safety, and strategic management of wait times, including the appropriateness, prioritization, length and management of the waiting experience.
Although the site of care is increasingly shifting from hospitals to a number of community and other settings, for example home care and long-term care, the healthcare system has not kept up in terms of ensuring that patients receive comprehensive and coordinated care in due time as they move through a fragmented and complex "system." Care provided outside of hospitals may also fall into a mixed domain of public and private financing, even though the two sectors are not coordinated. Policy makers, managers and providers need solid evidence of effective interventions, and practical solutions to amending health care across the continuum, as well as the means for overcoming the barriers to achieving these goals. There is also a lack of information on how governance, financial and delivery arrangements impact the delivery of timely, effective care, especially in the area of chronic disease prevention and management. Decision-makers need information and implementation strategies that exemplify how to shift from a system of acute care solutions for chronic care needs to a system of chronic care solutions for chronic care needs.
Realignment of existing capacity is necessary to meet the health care needs of Canadians across the continuum of care; in some areas more capacity is desperately needed; in others, existing capacity should be redeployed. As such, effective health human resource planning, management and training are vital for a responsive healthcare system. Change in scope of practice and practice models, as well as improved collaboration and information sharing, is required to ensure quality care and the most efficient use of the healthcare workforce. Change management and leadership development skills are critical to support this transition.
Within the strategic priority research area of Access to Appropriate Care across the Continuum, CIHR-IHSPR has identified the following key areas for research:
Health human resources
Chronic disease prevention and management
Strategic management for timely treatment
The financing, sustainability and governance of Canada's healthcare system have been the focus of vigorous discussions and debate. These issues are often framed in terms of the ability of governments to adequately finance health care in the face of growing demand and cost pressures (e.g., population aging, new drugs and technologies, and consumer expectations), while maintaining timely access to high-quality and affordable health care. The underlying sustainability issue – balancing rising cost pressures against limited public resources and assessing necessary trade-offs – is also a major concern, and all the more so in the context of the expiry of the current Health Accord in 2014. Central to the financing and sustainability of the healthcare system are governance structures that support and incent evidence-informed and accountable decision-making throughout the system with a view to improved efficiency and patient outcomes. Despite the attention and debate surrounding these issues, there are significant gaps in knowledge. IHSPR will support research and knowledge translation activities that advance the current state of knowledge and contribute to evidence-informed decision-making on the financing, sustainability and governance of Canada's healthcare system.
Examples of priority areas of research within the Financing, Sustainability, and Governance priority include the following:
- Evidence related to the sustainability of the current mix of public and private financing (deployed as it presently is in varying degrees in different sectors and across different jurisdictions) and the effects of potential changes to the mix on accessibility, affordability, cost, appropriate use, continuity, and/or quality of care across different health care sectors.
- Defining sustainability in the context of Canada's healthcare system; identifying frameworks and metrics for measuring sustainability; and identifying best approaches and pathways to ensuring the sustainability of the healthcare system.
- The strengths and limitations of different models of financing health care services not covered by the Canada Health Act (e.g., pharmaceuticals outside of hospitals and long-term care) with specific regard to the sustainability of the healthcare system and the accessibility, affordability and quality of care for individuals.
- The impacts of out-of-pocket health care costs on patients and their families and the strengths and weaknesses of various policy initiatives (e.g., tax credits or deductions, individual savings plans) designed to mitigate these impacts.
- The strengths and weaknesses of various national and international financing arrangements and/or governance structures and their impact on the sustainability, accessibility, efficiency and quality of those healthcare systems.
- The state of the private health insurance market in Canada (e.g., what evidence exists? What are our gaps in knowledge?), the current strengths and limitations, and the risks and opportunities associated with its expansion.
- The effects of various health care financing and funding models on equity and access, health care experiences, and outcomes of: (1) patients, families and other informal caregivers; and/or (2) vulnerable and at-risk populations (e.g. Aboriginal peoples, the frail elderly, children and youth, individuals with mental illness, etc.).
- Governance structures that contribute to the sustainability of the healthcare system by supporting and incentivizing accountable decision-making; the efficient use of resources; coordinated and integrated health care delivery; and improved outcomes throughout the healthcare system (e.g., primary and community-based care, secondary care, etc) and at the appropriate level of responsibility (e.g., provincial, regional, local).
- The strengths and weaknesses of various funding models (e.g., pay-for-performance, activity-based funding, capitation, mixed payment systems) and their impact on outcome measures like quality of care, efficiency of care delivery, equity of access, appropriate use, cost and health outcomes.
- Ethical frameworks for resource allocation decisions associated with new and emerging drugs, technologies, and customized therapies and their effects on accessibility, appropriate use, and/or cost to individuals and healthcare system.
Healthcare decision makers need data and information systems that support them in addressing access, quality and safety issues. The Romanow Report,3 federal health accords, Health Council of Canada reports and many other national and provincial organizations have emphasized the urgent need to establish an information infrastructure to support reform efforts of Canada's healthcare system. Subsequent initiatives to build a health information infrastructure have included Canada Health Infoway's efforts, together with those of the provinces, to create and implement electronic health records (EHRs) to increase the complement of electronic databases and improve the compatibility and intra-operability of data across jurisdictions.
Despite these initiatives, significant gaps remain in our understanding of the challenges related to developing, implementing and maintaining health information systems. Understanding these challenges is critical to driving and shaping future investments, encouraging clinicians to adopt e-Health solutions, ensuring public confidence in the systems and using the information to inform policy and planning. National frameworks are needed to allow for stakeholder input into the development of effective health information systems and the secondary use of data by decision makers and researchers. This would facilitate improved data systems, their effective use to develop policy and monitor the system, and researcher access to data in order to conduct timely, cross-jurisdictional health services and policy research.
This strategic priority focuses on four thematic areas, including:
- Electronic health records (e.g., evaluation, implementation, secondary use of data, ethical & privacy issues)
- Improving the quality, access to, linkage of, and use of data by decision makers and health services researchers
- Linkability of datasets across jurisdictions
- Harmonizing data privacy laws and consent for use of data for health services research
CIHR-IHSPR has identified Drug Policy as a priority research area. Prescription medicines are a vital part of the Canadian healthcare system. They can save lives, treat diseases and improve the quality of life for many. Drugs have also helped ease the burden on the healthcare system by shortening and preventing hospital stays. However, prescription drug use presents several challenges to the healthcare system. For example: they are the fastest growing and second largest category of total health care expenditure in Canada;1 access to medicines varies across Canada due, in part, to the lack of harmonized drug coverage; and adverse drug-related events raise serious safety concerns. Governments across Canada are striving to address the challenges and ensure both good health outcomes and system sustainability.
First Ministers have agreed that no Canadians should suffer undue financial hardship in accessing needed drug therapies, and that affordable access to drugs is fundamental to equitable health outcomes for Canadians.2 In September 2004, First Ministers directed Health Ministers to establish a Ministerial Task Force to develop and implement a National Pharmaceuticals Strategy (NPS) to address the challenges and opportunities across the drug lifecycle related to three themes: access; safety, effectiveness and appropriate use; and sustainability. The NPS strategy includes actions to assess cost drivers and cost-effectiveness, including best practices in resource allocation and drug plan policies; to develop options for catastrophic pharmaceutical coverage and a National Drug Formulary; to improve access to breakthrough drugs for unmet health needs and non-patented drugs; and to enhance action to influence prescribing behaviour of healthcare professionals. Further research in these areas is required to provide the best evidence to support drug policy development and initiatives.
In addition research that centres on the three main themes identified in the NPS, there is also increasing interest in factors that influence patient care-seeking related to prescription drugs, where patients get their information, and the extent of their involvement in clinical decision making. The time is also ripe for research and evaluation of models for improving public engagement and input into drug policy formulation and resource allocation decision making. An assessment of the levels of familiarity among the public with well-understood evidence-based facts about the safety, effectiveness and cost-effectiveness of health care alternatives could inform providers and decision makers alike. As well, decision-makers need an improved understanding of the impact of the media and the influence that direct marketing efforts such as direct-to-consumer advertising, toll-free lines, patient forums and patient support groups have on care-seeking.
Within the priority research area of Drug Policy, CIHR-IHSPR has identified the following key areas for research:
- Effectiveness, safety and adverse events
- Policies for equitable access to medicines (e.g., provincial formularies, regulation, financing and sustainability)
- Citizen-centeredness and public expectations (e.g., direct-to consumer advertising, role of the media, role of the public in resource allocation decision-making)
- Canadian Institute for Health Information. 2007. "Drug Expenditure in Canada, 1985 to 2006." Retrieved from Drug Expenditure in Canada, 1985 to 2006
- Health Canada. 2004. First Minister's Meeting on the Future of Health Care 2004: 10-Year Plan to Strengthen Health Care. Retrieved from First Minister's Meeting on the Future of Health Care 2004
- Romanow RJ. 2002. "Building on Values: the Future of Health Care in Canada", Final Report, November 2002. Commission on the Future of Health Care in Canada.