With the 2004 Health Accord – a $41-billion, 10-year infusion of health dollars that topped up existing transfers from Ottawa to the provinces – set to expire Monday, defenders of medicare are staging protests across the country Monday to demand the federal government take a leadership role in shaping a national health care system.

The Conservative government, which views health care delivery as strictly a provincial responsibility, has refused to negotiate a new agreement and will continue to limit its role to ongoing transfers of money to the provinces. This year's transfer is $32-billion; that amount will increase by six per cent annually until 2017, and after that increases will be tied to the performance of the economy. However, unlike under the Health Accord, there will be no conditions on how the money is used.

Between the two are provinces who would like Ottawa as a partner but nonetheless appreciate the steady stream of cash, and policy-makers who worry that the current system lacks both leadership and impetus for reform from either the federal or provincial governments.

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"What's going on now is like a long teenage break-up," said Adalsteinn Brown, director of the Institute of Health Policy, Management and Evaluation at the University of Toronto. "Everybody knows the relationship is changing but they don't want to have the difficult conversation. So we plod along."

Mike McBane, co-ordinator for the Canadian Health Coalition, said the void left by the expiry of the Health Accord is symbolic and troubling.

"What we really want is a commitment from all the parties that they will secure the future of healthcare," he said. "A Health Accord is just one mechanism for achieving that."

The coalition has protests planned at 42 sites on Monday, including a large rally in Toronto that will feature actress Shirley Douglas, the daughter of Tommy Douglas, the "father of medicare."

"I think the federal government should be the guardian of national medicare and they are abandoning that role," she said in an interview. "I'm ready to fight for medicare and I hope other Canadians are too."

Her son, actor Kiefer Sutherland, is also planning to release a videotaped statement on Monday.

The Health Accord – its formal name is the 10-Year Action Plan on Health – was negotiated by the First Ministers in 2004. The federal government committed to spending an additional $41-billion over a decade, and in return the provinces gave vague assurances that they would reduce wait times for surgery, bolster homecare, improve primary care, develop a national pharmaceuticals strategy and invest more in health promotion and prevention.

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Wait times in five key areas – cancer care, heart surgery, hip replacements, diagnostic imaging, and cataracts – got the most attention and the $5-billion invested produced modest results. But there was little appreciable change in the other areas in many provinces.

Ottawa makes lump sum payments to the provinces each year using the Canada Health Transfer (CHT). Rather than negotiate a new deal, Ottawa unilaterally adjusted the CHT: From 2017 to 2025, the increase will be equivalent to growth in gross domestic product plus three per cent until 2025.

"The provinces have been quiet because there's really no downside to that offer – it's money with no strings attached," Mr. Brown said. "What makes me sad about the Accord is the lost opportunities."

Mr. McBane believes Ottawa should put conditions on transfers as a way of ensuring equity in care across the country, and promoting specific reforms (like in pharmacare).

He also noted that at the beginning of medicare, the federal government covered 50 per cent of health costs; Ottawa's contribution has gradually decreased to about 20 per cent today and it is predicted it will fall to 12 per cent within 25 years with the new funding formula.

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