Canada's premiers are taking the lead on health-care reform without direct leadership from Ottawa, a departure from the way the country's cherished but increasingly expensive system has long been managed.
On Thursday, the premiers took their first steps to make health care less costly and more efficient, announcing a plan to save provinces millions of dollars on prescription drugs by purchasing generics in bulk.
But these changes are only the beginning, premiers told The Globe and Mail at a conference in Halifax.
"This is a process, not an event," said Saskatchewan Premier Brad Wall, who co-wrote a report on health reform with Prince Edward Island Premier Robert Ghiz.
Mr. Wall and Mr. Ghiz said they are responding to a lack of leadership from Ottawa and that the provinces are determined to pursue change on their own.
"We decided, as provinces, we don't need the federal government. … We run the health-care system," said Mr. Ghiz, adding that the "only thing" the federal government does is "provide a cheque for about 20 per cent of the costs. "
By acting alone, the premiers are answering Ottawa's call to action. Late last year, Prime Minister Stephen Harper granted provinces more autonomy to reshape health care as Ottawa moves to end 50 years of using its funding power to coerce provinces to adopt national standards.
Mr. Harper essentially asked provinces, with some federal guidance, to do as they see fit in their own jurisdictions while inviting them to co-operate in establishing national benchmarks for delivering health services.
The next step, Mr. Wall said, is to explore more bulk-purchasing options, including equipment. He said the provinces will also work together to reduce medically unnecessary testing, citing evidence that suggests up to 20 per cent of some medical imaging is not required.
At their meeting – which was nearly overshadowed by sparring between Alberta and B.C. over the proposed Northern Gateway pipeline – the premiers were critical of Ottawa for not negotiating a new health accord. But some premiers said they will simply fill the leadership void.
"We deliver the health care. … They said they didn't want to talk health care with us," Mr. Ghiz said of Ottawa.
Federal Health Minister Leona Aglukkaq, however, congratulated the premiers on their report, adding that bulk buying generic drugs is within the premiers' "purview to make decisions of that nature to manage how they deliver health care."
Ms. Aglukkaq defended the federal government's role in the health-care debate: "We have played a huge leadership role."
Some health-care advocates are concerned the federal government is not at the table. Michael McBane, the national co-ordinator of the Canadian Health Coalition, said the premiers were being too polite.
"They are treading water because they don't have a federal partner," he said, adding that the federal government has more responsibility than financing.
And some premiers do not believe the health report goes far enough. Ontario Premier Dalton McGuinty said it was a good first step, but that Ontario is "going a little further and perhaps moving a little quicker than they are considering in this report."
On generic drug costs, he said, his government has already saved Ontario residents more than half a billion dollars annually.
In addition, Mr. McGuinty said physician compensation should be considered closely because it represents one-quarter of all health-care costs. He has had discussions with Alberta Premier Alison Redford, who told The Globe that doctors' salaries have an impact across the country and that the two provinces have been working closely on the subject.
Quebec Premier Jean Charest, meanwhile, said his government will have to look at the bulk-buying plan for drugs because his province has its own system.
"It's not an adversarial approach," he said of not endorsing the drug strategy immediately. "We want to make sure there's an alignment of what our policies are with what the policy of the group is."
While it is not unusual to have some animosity toward Ottawa at a premiers' meeting, this one has seen increased tension – with many premiers not only critical of Mr. Harper's decision to set terms on how health care will be funded but to avoid first ministers meetings altogether. The Prime Minister has convened only one since 2008.
The premiers tried a different tactic on Thursday, appealing to Mr. Harper's focus on the economy and urging him to join them at a first ministers meeting in the fall to address the uncertain global economy and what it means for Canadians.