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Preliminary observations - Country visit to Canada, 5 to 16 November 2018


UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health
Mr. Dainius Pūras

Ottawa, 16 November 2018

Members of the press, 
Ladies and gentlemen,

I would like to begin by sincerely thanking the Government of Canada for inviting me to assess in a spirit of dialogue and cooperation, the realization of the right to physical and mental health, including good practices and remaining challenges. I highly appreciated the level of cooperation by the federal authorities in close coordination with provincial and local governments towards the good realization of my country visit.

During these 12 days, I travelled to Ottawa, Winnipeg, Vancouver and Montreal to visit health care facilities and meet with public officials and a wide-range of stakeholders. I met with the Government of Canada‘s Ministers of Health and Indigenous services and with a number of federal and provincial Governments’ representatives, including the Chief Public Health Officer of Canada and provincial Chiefs Medical or Health Officers, as well as officials in charge of health services at the Correctional Service Canada, including the Commissioner. I also met with independent bodies such as the Canadian Human Rights and Mental Health Commissions, the Correctional Investigator, a provincial youth Human Rights Commission, as well as officials of a provincial Ombudsman Office. I had the opportunity to additionally meet with a great variety of committed civil society representatives in each of the cities I travelled to, and visited a great variety of health care facilities from community-based centres and clinics, to large hospitals, where inter alia, mental health and youth services are provided. I also visited one high-school in Montreal.

Throughout my mission, I was able to verify the complex machinery of policy and technical schemes involved in Canada‘s delivery of health services and the different levels of responsibilities and jurisdictions of the Federal, Provincial/Territory and Cities’ authorities. Canada is also rich in research and data production, although more should be done in producing disaggregated data. I received a wealth of information that will take me some time to comprehensively review and that I hope to faithfully reflect in my report. Herewith, I am presenting only some preliminary findings, mainly based on my discussions and on what I was able to observe through my site visits to health facilities.

Before continuing, I would like to inform that in this room, you will find a short document that explains my responsibilities as the UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, as well as the in-focus themes for this visit. I am an independent expert who reports to, and advises, the United Nations Human Rights Council and General Assembly on the realisation of the right to physical and mental health.

International Legal framework

Canada is a party to seven core international human rights treaties, including the International Covenant on Economic, Social and Cultural Rights (ICESCR), which establishes the right to health.

While Canada is yet to ratify important treaties, including the Optional Protocol that would allow individuals to submit complaints on  alleged violations of the right to health, I am encouraged by Canada‘s acceptance of the Universal Periodic Review (UPR) recommendation aimed at ensuring justiciability of economic, social and cultural rights, in September 2018. It is true that the commendable public health approach that Canada adopted years ago includes advanced standards that are compatible with the right to health’s essential elements of accessibility, availability, acceptability and quality as well as access to health related information, education and information, including on sexual and reproductive health rights. However, Canada is yet to take the leap to comprehensively incorporate a right to health perspective, fully embracing the understanding that health, beyond a public service, is a human right.

I am optimistic that by accepting this UPR recommendation, the way will be paved for the effective justiciability of the right to health, in line with Canada‘s binding obligations under international human rights law. I have no doubt that the decision of August 2018 by the United Nations Human Rights Committee in the Toussaint v Canada case has shed light on the interconnection of rights and legal grounds to interpret that violations to the right to life and the right not to be discriminated may occur when there are failures to provide essential health care, notably when the concerned person is in a situation of vulnerability. Therefore, I look forward to the Government’s positive measures to protect health-related rights to life, security of the person, and equality of individuals and groups in situation of vulnerability, as also stipulated in the Canadian Charter of Rights and Freedoms, sections 7 and 15. I will be also attentive to the Canadian Courts’ role in ensuring access to justice and effective remedies when these rights, in conjunction with the right to health, are violated.

Advancing the realization of the right to health and related human rights in Canada is key in closing existing gaps in two ways. First, it will help ensuring good health and well-being of all people living in Canada, including groups in vulnerable situation such as indigenous peoples, undocumented migrants, persons in situation of poverty, persons with disabilities, including those with mental health conditions, persons with autism, and people who use drugs, to mention only some. Second, Canada is an important player in the international cooperation and a role model for many countries. It is therefore important that the international support provided by the Government of Canada is in line, not only with evidence-based, but with human rights based approach.

During my visit, I was interested to observe and understand both good practices as well as remaining obstacles, challenges and gaps. Canada is a highly developed country that has achieved much in standard of living; it has good economic and social indicators, and a large number of Canadians enjoy a good standard of health care. However, Canada still faces structural remaining gaps in the realization of the right of everyone to highest attainable standard of physical and mental health.

National health system

The provision of health services in Canada’s federal system implies a division of responsibilities between the Federal and Provincial/Territory Governments which has resulted in discrepancies to access quality healthcare by province and territory. 

Canada’s Federal Government sets the national direction for health care and the national standards, providing the funding for Provinces/Territory’s delivery of health care, through cash contributions. With these federal transfers, Provincial/Territory Governments administer, organize and deliver health care services. Federal transfers are subject to compliance with certain requirements, set out in the Canada Health Act. If any of the Provinces or Territories fail to meet the criteria, or if they allow extra billing by medical practitioners or user charges for insured health services, they will face a penalty in the form of reduction or withholding of the federal transfer.

The existing criteria to deliver federal transfers follow a public health approach which could be further enhanced with a human rights approach. This way, the Federal Government could effectively comply with its international human rights obligations, while at the same respecting the Provincial/Territory jurisdiction of health care delivery. The Federal Government could strengthen its public health approach with human rights-based criteria that permits the withholding or reduction of federal transfers when human rights elements are not protected, respected and/or fulfilled. The right to health framework provides concrete standards including accessibility, availability, acceptability, quality, informed consent, non-discrimination, participation and the relevance of addressing underlying determinants of health, amongst others that could be integrated into existing criteria for federal transfers.

To put in the words of a stakeholder: the quality of health services in Canada is very good if you can access them. This means that remaining gaps exist, and these mainly refer to groups in vulnerable situation which continue to face barriers in accessing health care services. Additional remaining gaps in health care delivery refer to the areas that are not covered by the public health care system, including medications, vision and dental care as well as psychosocial interventions. I will elaborate these issues further in my report.

During my visit, I could appreciate the very good work of civil society organizations in contributing to close remaining gaps. These organizations sometimes receive some funding from the Federal and/or the Provincial Government and have developed innovative approaches and models of intervention often including a human rights approach, even if not explicitly. These include Manitoba-based Action Marguerite Palliative care, NorWest Centres for vulnerable people and Ndinawe (addressing youth’s drug use in an integrated manner); Vancouver-based Dr. Peter Center (for persons living with HIV-AIDS) and Foundry (addressing youth’s right to health and underlying determinants in an integrated manner), as well as Doctors of the World Migrant Clinic in Montreal.

I was pleased to corroborate that the Federal and Provincial Governments recognize these good models. I would like to also recall that the obligation to protect, respect and fulfil the right to health continues to remain with the Government. While partnerships, recognition and replication of human rights-based grass-roots models brought forward and implemented by the civil society is to be commended, these do not exempt the Canadian State of its obligations under international human rights law. In the case of Canada, integrating the right to health is not a difficult big step, provided the very good public health approach already incorporated in health care delivery, including in particular the great recognition by policy-makers of the crucial need to address the underlying determinants of health.

My recommendation is that the Government of Canada continues to support the good projects of civil society, while at the same time investing and building capacity within the public health care system. This should be joined to my previous remarks about  applying rights-based criteria in health-related federal transfers to Provinces/Territory’s. The long-run goal would be that the Government uses and strengthens the expertise of civil society, mainstreaming their human rights based models into the public health system. The level of governance and cooperation between federal authorities and provincial authorities should also be strengthened in order to prevent miscommunications.

Mental health

During the last years and decades, Canada has invested substantially in mental health promotion and prevention of mental health conditions, as well as in treatment and rehabilitation of psychosocial disabilities and other mental health conditions. There are many good practices in different provinces that are to be commended and replicated throughout Canada and worldwide, especially in the area of child and youth mental health services. I will elaborate further on this in my report.

However, I would also like to urge Federal and Provincial authorities to further advance the realization of the right of everyone to mental health and the realization of all human rights of persons with psychosocial, intellectual and cognitive disabilities.

Firstly, determinants of mental health, such as inequalities, discrimination and violence need to be addressed with enhanced political will and increased investments, so that the risk factors for poor mental health outcomes can be effectively prevented. In this regard, overcoming early childhood adversities is of key importance, considering their detrimental impact and correlation with a higher prevalence of different patterns of poor physical and mental health, including suicides, epidemics of deaths from opioid overdose, and poorer outcomes in indigenous peoples’ health, amongst others.

Secondly, Canada could and should be champion in critically assessing the current situation of mental health policies and services, both domestically and globally, and in modernizing mental health policies and services through international support. Canada‘s international cooperation should be directed to the provision of rights-based mental health services and should move away from services based on over-medicalization and coercion, in compliance with the Convention on the Rights of Persons with Disabilities. These should be obligatory conditions to apply for international Canadian support. I see good opportunities for this substantial progress and I will be elaborating more on this in my report.

The overall main goal is to achieve parity between mental and physical health in the provision of health services. But for this to happen, policy decisions need to be made in order to prioritize investments to those services that are in line with human rights based approach and that do not feed the vicious cycle of discrimination, stigma, exclusion and overuse of the biomedical model.

During my visit to Vancouver General Hospital, I observed the high level of quality of specialized physical care for people who need intensive care or other physical care, jointly with a good management of admissions and referrals. These same high levels should be reached when issues related to mental health and substances use appear; but for this to happen, different innovative solutions are further needed other than just investing in biomedical interventions. This is why it is so important to address imbalances in the provision and funding of health related issues

The movement Choosing Wisely Canada provides relevant clues in this connection by attempting to reduce unnecessary tests, treatments and procedures.

Indigenous peoples

The process of reconciliation and Prime Minister Trudeau‘s acceptance of recommendations from the Truth and Reconciliation Commission Calls to Action; The recognition and renewal of relationships with Indigenous authorities; The apology of former Prime Minister Harper, followed by apologies of all provinces and territories admitting that residential schools were part of a policy on forced Indigenous assimilation, and Prime Minister Trudeau‘s removal of Canada’s objector status for the United Nations Declaration of the Rights of Indigenous Peoples, are all important and necessary steps towards ending the detrimental effects of colonialism and its practices. However, these essential steps continue to be just the first ones in  a large list of needed efforts to effectively addressing the historic and structural underlying determinants of health of indigenous peoples. The legacy of residential schools is just one of the examples of the devastating effects that policies and practices, sometimes with good intentions, can have on the human rights and dignity on persons and notably on those in vulnerable situation.

I had many meetings with representatives of indigenous peoples: First Nations, Inuit, and Métis, including the unique Firsts Nations Health Authority in British Columbia who, in coordination with Provincial and Federal authorities is now delivering health services in remote reserve communities.

Although many efforts have been made to invest in health-related policies and services, the situation remains far from good, and representatives of indigenous peoples have shared many examples of services being either difficult to access or not culturally appropriate. I would like to highlight the situation of First Nations community in Red Sucker Lake at Northern Manitoba, which continues to face various challenges in accessing health care; the situation of First Nations Grassy Narrows whose health outcomes continue to be affected by mercury poisoning, industrial logging, and lack of access to potable water, as well as the situation of Inui peoples in Nunavut who continue to report disproportional rates of tuberculosis. The current Federal Administration has recognized the health-related challenges in these three communities, but much remains to be done to effectively addressing them. I will elaborate on these challenges and progress in my report.

Overall, a serious systemic problem of lack of trust continues in-country and this may be the reflection of remaining de-facto discriminatory attitudes.

Indigenous peoples are massively overrepresented among those who use drugs and die from opioid overdose, among those who have mental health conditions, who commit suicide and who are incarcerated. These phenomena indicates the existence of cross-cutting risk factors that affect the health of indigenous peoples and the need to develop culturally appropriate responses. These phenomena also show that medicalized health and mental health services cannot be effective solutions of modern times, and that broader health related policies that effectively address the underlying determinants of health need to be prioritized.

Drug use

I commend Canada, both federal and provincial authorities, for their leadership in investing in modern human rights approaches domestically and internationally, and for taking steps towards the decriminalization of drug use, which on the other hand continues to exist. I visited good practices of supervised consumption centres and overdose prevention sites in Vancouver which have been granted exception of the federal drug-related criminalization. These type of centres, however, seem to be insufficient and should be replicated within British Columbia and across the country. The Opioid overdose crisis is of such gravity that it may not be an exaggeration to compare it with the HIV/AIDS epidemics. While very good efforts are being invested to address the crisis, I urge authorities to doubling efforts to continuing addressing its root causes and underlying determinants of health, including poverty, discrimination, early childhood adversities, access to adequate housing and safe water, and access to healthy occupational and environmental conditions.

Other issues

Canada has taken good efforts in favour of sexual and reproductive health rights, however there are some signs of retrogressive measures such as Ontario’s Government elimination of the 2015 sexuality education curriculum in favour of reinstating the 1998 sexuality education curriculum which misses key content in terms of consent, challenging homophobia, internet safety and information on a diversity of gender identities and sexual orientations.
Among the good practices, I should stress sexuality education in Lester B. Pearson High School, which I had the pleasure to visit and learn from during my visit in Montreal.

I observed and discussed many additional issues related to the in-focus themes of my visit on which I will elaborate further in my report. For example, I received information about additional challenges including, inter alia, criminalization of both sex work and of HIV non-disclosure; access to contraceptives and abortion services, access to HIV medication, remaining practices of obstetric violence and forced sterilization amongst indigenous women, and the situation of vulnerability of incarcerated women, among whom indigenous and Afro-Canadian women are disproportionately represented.

Members of the press,
Ladies and gentlemen,

Remaining challenges in Canada show the need to apply a human rights based approach. Investments with adequate financial and human resources in health are important and Canada is doing rather well in this regards; so the crucial issue is the direction and prioritizing of resources, as well as rights-based conditions for federal health-related transfers. Cross-cutting to this is the issue of investing in the public health priorities of modern times, namely the so-called “new morbidities” in children and adults such as mental health, underlying determinants of health, addressing drug use issues, adolescent and youth health related issues, including monitoring mechanisms to make sure that all the elements of an analytical right to health framework are in place.

Thank you.