Federal Investments in Palliative Care

After the Parliamentary Budget Officer (PBO) released the cost estimate for Bill C‑7 (medical assistance in dying), he was asked to identify federal investments in palliative care made since Canada had legalized medical assistance in dying.[i]

Palliative Care Framework and Action Plan

On 30 May 2016, Sarnia—Lambton MP Marilyn Gladu introduced Private Member’s Bill C-277, An Act providing for the development of a framework on palliative care in Canada. The bill received Royal Assent on 12 December 2017. According to the preamble, “a request for physician-assisted death cannot be truly voluntary if the option of proper palliative care is not available to alleviate a person’s suffering.” This legislation requires the Minister of Health to develop a framework for palliative care and report to Parliament within a year after the Act comes into force. The Minister must table another report on the state of palliative care in Canada within five years of tabling the framework.

The government released its framework on palliative care in Canada in December 2018.[ii] Through information request IR0554 (November 2020), the PBO received details on the cost of developing the framework, which totalled $83,000 in 2018–19. In August 2019, the government published an action plan on palliative care, in keeping with its commitment in the framework.[iii] The action plan cost $6,000 to produce in 2019–20. The framework also states that “Health Canada will establish the Office of Palliative Care (OPC) to provide high level coordination of activities going forward. The OPC will be resourced internally through existing funds within Health Canada.” The OPC has generated costs of $33,000 from 2016–17 to date.[iv]

Through the information request to Health Canada, we also learned that the government spent $38,000 in 2016–17 on outside contracts, including a survey on potential national activities to improve palliative care and the identification of provincial/territorial priorities for palliative care.

The federal government’s most significant expenditures involve funding for various projects to support palliative care. In total, the government has spent more than $13 million since 2016–17 and expects this amount to increase by the end of 2020–21, as other projects are still in development and have not been officially announced. Table 1 offers a breakdown of expenditures to date, by fiscal year.

Federal investments in palliative care (2016–17 to date)
Table 1

Source: Health Canada

Category	2016–17	2017–18	2018–19	2019–20	2020–21	Total ($)
Framework on palliative care			83,087			83,087
Action plan on palliative care				6,163		6,163
General contracts	38,150					38,150
Office of Palliative Care	2,000	3,000	11,046	9,565	7,395	33,006
Funded projects through grants and contributions	868,521	1,839,000	3,165,400	4,501,684	3,192,628	13,567,233
Total	908,671	1,842,000	3,259,533	4,517,412	3,200,023	13,727,639

Bilateral Agreements

Budget 2017, tabled in the House of Commons on 22 March 2017, announced $6 billion in funding over 10 years for home care and $5 billion over 10 years to support mental health initiatives. The purpose of this funding is to ensure “improved access to home, community and palliative care services; more support for informal caregivers; and better access to mental health support.” Budget 2017 also provided for the following expenditures over a five-year period (chapter 3, page 193):

Source: Budget 2017, Department of Finance Canada

($ millions)	2017–18	2018–19	2019–20	2020–21	2021–22
Home care and mental health	300	850	1,100	1,250	1,500

In August 2017, the provinces and territories (aside from Quebec) agreed on a common statement of principles on shared health priorities.[v] Between 2017 and 2019, the federal government subsequently signed bilateral funding agreements with each province and territory.[vi] Each province and territory developed an action plan, usually appended to the bilateral agreement, that specified how the federal transfers would be used. However, only six provinces identified initiatives specific to palliative care (British Columbia, Alberta, Saskatchewan, Manitoba, New Brunswick, and Newfoundland and Labrador). According to the provinces’ bilateral agreements, the total funding for palliative care initiatives for these six provinces will be $170 million from 2017–18 to 2021–22. Table 2 shows palliative care spending as provided for in the bilateral agreements.

Palliative care initiatives according to bilateral agreements
Table 2

Source: Funding agreements between Canada and the provinces on home and community care, and mental health and addictions services

($ thousands)	2017–18	2018–19	2019–20	2020–21	2021–22	Total
British Columbia
Palliative and end-of-life care	4,930	11,810	12,800	12,800	17,710	60,050
Alberta
Enhancing access to palliative and end‑of‑life services	3,200	8,100	8,100	8,100	8,100	35,600
Saskatchewan
Palliative care enhancements	700	2,420	3,820	5,000	5,000	16,940
Manitoba
Hospice and palliative care services			600	2,000	3,600	6,200
New Brunswick
Palliative care strategy		2,500	3,000	3,000	3,000	11,500
Newfoundland and Labrador
Home First integrated network
Additional clinicians for palliative/complex care	2,820	3,100	3,230	3,290	3,770	16,210
Enhanced access to palliative/complex/dementia care		3,940	4,530	3,970	7,100	19,540
Palliative care/end-of-life improvement
Public awareness campaign for advanced health care planning		100				100
Additional hospice bed capacity		1,100	1,100	1,100	1,100	4,400
TOTAL	11,650	33,070	37,180	39,260	49,380	170,540

For other provinces and territories, palliative care is generally part of broader initiatives, such as expanding access to home care in Ontario, which also includes palliative and end-of-life care at home. Unfortunately, the specific amounts allocated to palliative care are not available for these provinces and territories. Because health is a provincial jurisdiction, Health Canada does not have access to, or the authority to request, program-specific accounting. Similarly, section 79.4 of the Parliament of Canada Act entitles the PBO to access information only under the control of federal departments or Crown corporations. The companion document “Annex - Bilateral Agreements,” which can be downloaded from the PBO website, contains tables detailing the amounts allocated to all initiatives funded under the bilateral agreements by province/territory, as presented in the annexes to these agreements.

Looking at the totals of bilateral agreements by province/territory for each fiscal year, they are almost identical to the amounts announced in Budget 2017. PBO has therefore sought, through Information Request IR0554, the actual amounts disbursed by the federal government for each fiscal year. Table 3 provides this breakdown by province/territory, by fiscal year. It shows that the amounts are generally quite close to those announced in the bilateral agreements.^[vii] The agreements specify that the overall envelope for each fiscal year is distributed among the provinces and territories based on the quarterly preliminary estimates of their respective populations on 1 July of the same fiscal year, published by Statistics Canada each September. This mainly explains the discrepancies between the amounts announced and those actually transferred.

Amounts actually transferred to the provinces/territories under the bilateral agreements
Table 3

Source: Health Canada

($)	2017–18	2018–19	2019–20	2020–21	Total
British Columbia	39,284,212	114,491,768	148,405,936	169,309,294	471,491,210
Alberta	35,160,909	98,789,976	127,920,777	145,436,400	407,308,062
Saskatchewan	9,512,913	26,653,621	34,369,076	38,767,058	109,302,668
Manitoba	10,897,695	31,013,664	40,075,581	45,364,240	127,351,180
Ontario	115,605,084	328,513,742	426,270,716	484,604,714	1,354,994,256
Quebec	68,836,395	192,448,578	248,301,270	282,019,383	791,605,626
New Brunswick	6,256,720	17,675,614	22,732,814	25,702,904	72,368,052
Prince Edward Island	1,228,964	3,514,879	4,592,847	5,250,098	14,586,788
Nova Scotia	7,850,051	22,017,698	28,426,589	32,211,054	90,505,392
Newfoundland and Labrador	4,382,862	12,049,798	15,262,236	17,172,073	48,866,969
Nunavut	367,650	0	880,671	1,134,846	2,383,167
Northwest Territories	367,650	1,021,614	1,311,774	1,485,354	4,186,392
Yukon	309,967	928,377	1,195,538	1,383,098	3,816,980
Total	300,061,072	849,119,329	1,099,745,825	1,249,840,516	3,498,766,742
Budget 2017	300,000,000	850,000,000	1,100,000,000	1,250,000,000	3,500,000,000
Difference	61,072	-880,671	-254,175	-159,484	-1,233,258

Table 3 also shows that Nunavut did not receive a transfer for 2018–19, likely due to the fact that the bilateral agreement with the federal government was not signed until March 2019. Note that 2020–21 is not yet complete and that Health Canada advised us that the November payment (the second of two annual payments) had not yet been made at the time of the information request because the annual financial statements required in sections 4.3.1(e) and 5.1.2(b) of the bilateral agreement had not yet been produced.^[viii] The Northwest Territories are in the same situation. Since each payment is supposed to represent 50% of the annual total, it is possible that the actual amount paid to date for 2020–21 may only be $567,423 (half of $1,134,846) for Nunavut and $742,677 for the Northwest Territories.

Conclusion

The PBO identified a total federal investment of $184 million between 2016 and today, specifically for palliative care. Table 4 presents the total investment in initiatives specific to palliative care by fiscal year. As mentioned earlier, these figures underestimate the investment for two reasons. First, the salaries paid to Health Canada officials involved in developing the framework and action plan on palliative care, as well as those working for the new Office of Palliative Care, are not included in this total. Since existing resources were reallocated to these tasks, Health Canada did not include their cost in its response to our information request.

Total federal investment in palliative care
Table 4

Sources: Health Canada and PBO calculations

($ thousands)	2017–18	2018–19	2019–20	2020–21	2021–22	Total
Federal investments in palliative care	909	1,842	3,260	4,517	3,200	13,728
Initiatives specific to palliative care in bilateral agreements	11,650	33,070	37,180	39,260	49,380	170,540
TOTAL	12,559	34,912	40,440	43,777	52,580	184,268

Second, other provinces that have not identified initiatives specific to palliative care in bilateral agreements have nevertheless likely allocated funds to expand the availability of palliative home care. Assuming that these provinces will allocate the same share of funding received for home and community care to palliative care as the provinces that identified specific initiatives (on average 16.2%^[ix]), there may have been an additional investment of $306 million. Table 5 provides estimates of the amounts allocated to palliative care under this assumption.

Estimated amounts allocated to palliative care initiatives assuming the same allocation of funds for home care as the average for other provinces
Table 5

Source: PBO calculations
Note: Nunavut and the Northwest Territories are not included in the table because all home care funds are allocated to initiatives that do not appear to directly include palliative care.

($ thousands)	2017–18	2018–19	2019–20	2020–21	2021–22	Total
Ontario	12,472	37,543	40,673	40,673	56,315	187,676
Quebec	0	22,203	24,054	24,054	33,305	103,617
Prince Edward Island	133	401	435	435	604	2,008
Nova Scotia	846	2,515	2,719	2,719	3,764	12,563
Yukon	34	102	110	110	152	508
Total	13,485	62,764	67,991	67,991	94,140	306,372

Although the Quebec government had promised additional palliative home care groups in 2017, it was not until December 2019 that an agreement was reached with the Fédération des médecins omnipraticiens du Québec (FMOQ).^[x] As a result, the estimate presented for Quebec in Table 5 is most likely overstated for 2018–19 and 2019–20.

Lastly, all the bilateral agreements expire on 31 March 2022 (except for the Nunavut agreement, which expires on 31 March 2023) and will need to be renewed. The total of the amounts presented in the bilateral agreements corresponds to the total of $5 billion announced in the 2017 Budget for 2017–18 to 2021–22. Since the government promised in the 2017 Budget to invest $11 billion over 10 years, including $6 billion for home care and $5 billion for mental health and addictions initiatives, it can be assumed that renewing the agreements will provide an additional $3 billion for home care. Assuming that the provinces and territories still allocate 16.2% of this funding to initiatives specific to palliative care, we can expect an investment in palliative care of $485 million between 2022–23 and 2026–27.