Introduction
Canada’s publicly financed healthcare system is dynamic; adjustments have been made over the past 40 years and will continue in response to societal and medical advancements. The fundamentals, however, remain the same: universal coverage for health services that must be given for medical reasons and are paid for according to need rather than means.
Background
The Canadian health care system exhibits the fundamental principles of justice and equity that Canadians are willing to share resources and responsibilities. And these principles have been reflected in the system’s adjustments and significant revisions since it was first implemented. As the population and conditions of the nation change, as well as the nature of health care itself, the system has been and is still being updated.
Health Care System’s Evolution
In general, the federal, provincial, and territory governments’ powers are outlined in Canada’s Constitution. The establishment, maintenance, and administration of hospitals, asylums, charities, and charitable institutions fell under provincial purview by the Constitution Act of 1867, while quarantine and naval hospitals were placed under the federal government’s purview.
Additionally, the federal government was given the authority to tax, borrow money, and spend it as long as it did not conflict with provincial authority. Between 1867 through 1919, when the department of Health was established, the federal department of Agriculture oversaw all government health-related duties. The duties of both levels of government have evolved throughout time.
Before World War II, most of Canada’s health care was provided and paid privately. The Saskatchewanian government established a universal hospital care program in 1947. Alberta and British Columbia both had comparable plans by 1950. The federal government approved the Hospital Insurance and Diagnostic Services Act in 1957, providing reimbursement or cost-sharing for one-half of the expenses incurred by the provinces and territories for a list of hospital and diagnostic services.
This Act established consistent terms and conditions for publicly managed universal coverage of a particular set of services. The provinces and territories agreed to offer publicly supported inpatient hospital and diagnostic services four years later.
In 1962, Saskatchewan established a comprehensive provincial medical insurance program to cover all its citizens’ medical care access. The Medical Care Act, which the federal government approved in 1966, promised to protect or cost-share one-half of the costs incurred by the provinces and territories for medical services rendered by physicians outside hospitals. The universal physician services insurance programs were implemented in all of the provinces and territories within six years.
Cost sharing was replaced with a block fund in 1977 due to the Federal-Provincial Fiscal Arrangements and Established Programs Financing Act, which in this case, consisted of a mix of cash payments and tax points. Block funds are sums of money that are transferred from one level of government to another for a particular use.
When tax points are transferred, the federal government lowers its tax rates while raising the provincial and territorial tax rates by the same amount. The regional and territorial governments now have the freedom to allocate health care money by their needs and priorities to the new funding model. In addition to the health transfer, there are federal transfers for higher education.
The Canada Health Act, federal legislation, was adopted in 1984. The requirements on mobility, affordability, equality, completeness, and public service were established by this legislation to replace the national hospital and medical insurance acts and to consolidate their ideas. The Act also included prohibiting further invoicing and user fees for covered services.
The Canada Health and Social Transfer (CHST), which went into effect in 1996–1997, was created due to federal legislation passed in 1995 that combined federal cash and tax transfers for health care and post-secondary education with federal transfers for social services and social assistance.
Critical improvements in primary healthcare, pharmaceuticals management, health information, communications technology, and medical infrastructure were outlined in a health accord concluded by the heads of the federal, provincial, and territory governments (or first ministers) in 2000. The federal government also boosted financial disbursements for health care at the same time.
The Accord on Health Care Renewal, which the first ministers approved in 2003, called for fundamental changes to the healthcare system to improve access, quality, and long-term sustainability. The Accord obligated nations to strive toward specific changes in areas, including faster primary healthcare renewal, supporting information technology, coverage for specific home care services and medications, improved access to diagnostic and medical equipment, and improved government accountability.
With the implementation of the Accord in April 2004, the CHST was divided into the Canada Health Transfer for Health and the Canada Social Transfer for post-secondary education, social services, and social assistance. Cash transfers from the federal government to support health care were also increased.
A 10-Year Plan to Strengthen Health Care, published in 2004, contained more measures than the first ministers announced. The federal, provincial, and territorial governments committed to a health care renewal plan that included work toward reforms in essential areas like wait times management, human health resources, Aboriginal Health, home care, primary care, a national pharmaceutical strategy, health care services in the North, medical equipment, prevention, promotion, and Public Health, as well as improved reporting on the progress made on these reforms.
To support the Plan, the federal government raised financial transfers for health care, notably the Canada Health Transfer, every year from 2006–07 until 2013–14. This helped to ensure predictable growth in federal financing.
All provinces and territories officially agreed in the spring of 2007 to adopt a Patient Wait Times Guarantee in one priority therapeutic area by 2010 and to launch pilot projects to evaluate the guarantees and guide their implementation. A patient wait times guarantee provides alternative treatment alternatives (such as a recommendation to another doctor or medical center) to patients whose wait times exceed a specific window during which medically required health services ought to be supplied.
The Role of Government
The Canadian Constitution, which assigns tasks and obligations to the federal, provincial, and territory governments, heavily influences how Canada’s healthcare system is organized. Most of the duty for providing social services like health care rests with the province and territory governments. A portion of the delivery of services to specific individuals is also the federal government’s responsibility.
Health care that is publicly supported is paid for using general revenue collected from federal, provincial, and territorial taxation, including income taxes paid by individuals and businesses, sales taxes, payroll levies, and other sources. To assist pay for publicly financed health care services, provinces may also impose a health premium on their citizens; however, non-payment of the bonus cannot restrict access to medically essential health treatments.
Health is more than just the availability of medical services. Each of the three levels of government—federal, provincial/territorial, and local or municipal—shares responsibility for public health, which covers sanitation, infectious illnesses, and associated education. However, the provincial/territorial and local levels are often where these services are provided.
The Federal Government
In terms of its responsibilities for health care, the federal government is in charge of establishing and enforcing the national standards for the Canada Health Act system, providing financial assistance to the provinces and territories, and performing several additional tasks, such as providing financing for and the provision of primary and supplemental services to specific populations. First Nations people who reside on reservations, the Inuit, active members of the Canadian Armed Forces, qualified veterans, prisoners of federal prisons, and various categories of refugee claimants are among these groups.
For provinces and territories to be eligible for complete federal funding transfers to promote health, the Canada Health Act outlines requirements and conditions for health insurance schemes. All provinces and territories are expected to offer appropriate access to hospital and physician services. Additionally, the Act forbids user fees and additional charging. Extra billing is when a doctor charges for covered health care more than what the provincial or territorial health insurance plan has already paid for or will pay in the future.
A user fee is any price for an insured health treatment that the Plan, other than extra-billing, does not cover. The Canada Health Transfer program, wherein the federal government distributes money and taxes to the provinces and territories to boost their health. The federal government also pays equalization payments to less prosperous areas and territorial finance to the regions to cover the expenses of publicly supported services, including health care.
In addition to community-based health programs on reserves and Inuit communities, direct federal service is delivered to First Nations people. This program is available to all First Nations people and Inuit. Inpatient treatment facilities, health centers, nursing stations, and community health promotion initiatives typically offer these services. Government agencies and Aboriginal groups are collaborating more to supply these services within the framework of the territory and provincial administrations.
In addition, the federal government is in charge of consumer safety, disease surveillance, and regulating medical equipment, food, and medicines. Additionally, it supports medical study and health promotion. Further, the federal government has implemented tax policies related to health, including tax breaks for private health insurance premiums paid by self-employed individuals, tax credits for medical expenses, disability, caregivers, and dependents with disabilities, and tax rebates for public institutions providing healthcare services.
The territorial and provincial governments
Most of Canada’s healthcare services are administered and provided by the provinces and territories. All their health insurance programs must adhere to the national standards established by the Canada Health Act. Each province’s and territory’s health insurance program pays for medically essential hospital and physician treatments that are rendered pre-paid and without upfront payments. These services are paid for by the provincial and territory governments with help from federal transfers of money and taxes.
The Canada Health Act does not define medically required services. Which services are considered medically essential for health insurance is a decision that must be made by the provincial and territorial health insurance plans in cooperation with their respective physician colleges or organizations. To conform with the Act, if it is decided that a service is medically required, the service’s total cost must be covered by the public health insurance plan. The province or territory is not required to pay for a service through its health insurance program if it is not deemed medically necessary.
The provincial and territorial governments play the following roles in health care:
- Planning and financing of treatment in hospitals and other healthcare facilities
- Services given by doctors and other health professionals
- Planning and execution of health promotion and public health programmes
- Negotiating fee schedules with healthcare providers
For certain groups such as low-income residents and seniors, the majority of provincial and territorial governments provide and finance supplemental benefits. And those supplemental benefits are medicines prescribed outside of hospitals, ambulance costs, and hearing, vision, and dental care, which the Canada Health Act does not cover.
Supplemental health care is mostly funded privately, despite the fact that the provinces and territories give some categories of individuals these additional benefits. Families and individuals who are not eligible for publicly supported insurance may choose to pay these fees out-of-pocket, enroll in a group health plan via their place of employment, or purchase private insurance. Private insurers are prohibited from providing coverage that is identical to that of publicly funded projects under the majority of provincial and territorial regulations. Still, they are allowed to participate in the market for supplemental coverage.
Every province and territory have an independent workers’ compensation organization that is supported by businesses and assists employees who sustain workplace injuries.
Health-Related Expenses
Health spending varies between provinces and territories within the publicly financed healthcare system. This is partly because each province and territory offer a different set of services and depends on demographic elements like population age. Other factors, such as regions with small and dispersed populations, may also influence health care expenses.
How Medical Services Are Provided
The best way to define Canada’s publicly financed healthcare system is as an interconnected collection of 10 provinces and three territory health systems. The system, which Canadians regard to as “medicare,” enables access to a wide range of healthcare procedures.
The initial procedure of Primary Health Care Services
Primary healthcare services are the primary point of contact with the healthcare system for Canadians seeking medical attention. Primary health care has a dual purpose in general. First, it offers first-contact direct delivery of healthcare services. When more specialized services are required, it organizes patients’ medical treatment to provide continuity of care and ease of mobility within the healthcare system (e.g., from specialists or in hospitals).
Primary health care services are becoming more extensive. They may include health promotion, healthy child development, primary maternity care, essential emergency services, referrals to and coordination with higher levels of care, such as hospital and specialist care, primary mental health care, palliative and end-of-life care, and rehabilitation services. They may also include the prevention and treatment of common diseases and injuries.
The typical method of paying doctors in private practice is through fee-for-service schedules that list each service and charge the doctor a fee for each service. These are negotiated with the medical specialties within each province’s and territory’s specific authority. A different payment method, such as salary or a mixed payment, is more likely to be used for those in other practice settings, including clinics, community health centers, and group practices. Salary agreements between businesses and unions are typically made when hiring nurses and other health workers.
Patients who need additional testing or treatment are, when required, referred to other healthcare providers, such as physician specialists, nurse practitioners, and allied health professionals, as well as other healthcare services, such as diagnostic testing.
Secondary Services
Depending on the patient’s needs, specialist treatment may be recommended at a hospital, a long-term care facility, or a community. Regional health authorities, non-profit groups, or community boards of trustees that were founded by provincial or territory governments run the majority of Canadian hospitals. In contrast to fee-for-service models, hospitals are often supported by yearly, worldwide budgets that are negotiated with the provincial and territorial ministries of health or with a regional health authority or board. These budgets define overall expenditure objectives or restrictions. Even though global financing remains the primary method of hospital reimbursement in Canada, certain provinces have been experimenting with additional funding methods.
Additionally, institutions and the community may offer secondary health care services (primarily long-term and chronic care). Doctors, hospitals, community organizations, families, and patients may refer patients to home, community, or institutional care. Medical experts evaluate the patient’s needs and coordinate services to ensure continuity of care. A variety of official, informal (typically family), and volunteer carers offer care.
The Canada Health Act does not cover most home and continuing care services; nevertheless, all provinces and territories supply and pay for some home and continuing care services. The range of services offered and how these programs are regulated differently. Veterans Affairs Canada, a federal department, provides some veterans home care services when those services are not offered by their province or territory. The federal government also provides home health care services to Inuit living in specific communities and First Nations people who reside on reservations.
Typically, housing and board expenses in long-term care facilities are covered by the resident, while health care services are covered by the province and territory governments. The provincial and territorial governments occasionally provide financial assistance with room and board costs.
Hospices, long-term care institutions, hospitals, community centers, and private homes are just a few places where palliative care is provided. Palliative care is geared toward people who are terminally ill and their families. It consists of grief counseling, medical and emotional support, pain and symptom control, and assistance with community resources and programs.
Additional Services
Some persons (such as seniors, kids, and residents with low incomes) are covered by the provinces and territories for health treatments that aren’t typically covered by the publicly financed health care system. Prescription medications outside of hospitals, dental treatment, vision care, medical equipment and appliances (prostheses, wheelchairs, etc.), and the services of other health professionals such as physiotherapists are all examples of supplemental health benefits. Various regions of the nation have different levels of coverage.
If a person is not eligible for additional benefits under government programs, they must pay for these treatments themselves or through private health insurance. Many Canadians have access to private health insurance, either via their employer or independently, and the amount of protection offered varies depending on the plan chosen.
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Health Human Resources
In Canada, little over 1,000,000 persons, or 6% of the overall workforce, were employed directly in the health sector in 2006. Health care providers can be unionized or not, hired, self-employed, or volunteers. They can also be regulated. The government does not employ most doctors; instead, they work in independent or group practices. Some are used by community health centers, hospital-based group practices, primary care teams, or organizations connected to outpatient hospitals.
Although nurses work primarily in acute care facilities, they also offer community health services, including home care and public health programs. Dentists work in individual clinics; only when in-hospital dental surgery is necessary are their services reimbursed by the publicly financed healthcare system. Dental hygienists, laboratory and medical technicians, optometrists, pharmacists, physio and occupational therapists, psychologists, speech-language pathologists, and audiologists are examples of allied health professions.
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Trends in Health Care
The Canadian healthcare system has encountered problems in recent years as a result of a variety of variables, such as changes in service delivery, economic limits, the ageing of the baby boom generation, and the high cost of new technologies. Future developments are anticipated to keep these elements in play.
From dependence on hospitals and physicians to alternative care delivery in clinics, primary health care centers, community health centers, and home care; treatment utilizing medical technology and pharmaceuticals; and a stronger emphasis on public health and health promotion since the introduction of publicly financed health care in Canada.
Due to medical advancements, more outpatient treatments are being performed and more day operations. Per capita, fewer Canadians have spent nights in acute-care hospitals over the past few decades. Still, the number of post-acute and alternative treatments offered in the home and community has increased.
By decentralizing decision-making on health care delivery to the regional or local board level, the majority of provinces and territories started working to control costs and enhance delivery in the middle of the 1990s. Nominated officials run these regional health authorities in charge of the local hospitals, nursing homes, home care, and public health services. However, the decentralized model of health care delivery has been abandoned in certain provinces in recent years in favor of fewer health authorities and centralized decision-making.
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Primary Care
The conventional primary health care paradigm, which is episodic and responsive, has benefited Canadians. However, the necessity for the health care system to sustain and further enhance the ability to respond to the altering requirements of Canadians has been highlighted by the aging population, growing rates of chronic disease, and other changing health trends.
More community primary health care centers that offer round-the-clock on-call services have been established as part of reforms, along with direct health care teams. Additionally, more emphasis has been placed on promoting health, avoiding sickness and injury, and treating chronic illnesses. The coordination and integration of comprehensive health services have also been increased, and the working conditions of primary health care personnel have been improved.
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eHealth
In Canada and numerous other nations, eHealth advancement has received much attention. By enhancing access to services, patient safety, quality of treatment, and productivity, electronic health technologies (such as electronic health records and telehealth) are essential drivers of innovation, sustainability, and efficiency in the healthcare system. By enabling efficient service integration and coordination between providers of care, the adoption and use of electronic health records support the revival of primary care.
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Wait Time Reduction
Under the priorities of their respective systems, provincial and territorial efforts to cut down on acute care wait times include training and hiring more health professionals, reducing treatment backlogs for patients, expanding ambulatory and community care programs, strengthening the capacity of regional centers of excellence, and creating and implementing tools to manage wait times better.
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Patient Safety
One of the most critical problems confronting health systems worldwide is patient safety, which includes preventing medical mistakes or unfavorable outcomes. In Canada, efforts are being made to raise the standard of care delivered throughout the health care system.
The federal, provincial, and territory governments continue to collaborate with organizations, institutions, and healthcare professionals to understand better and reduce the risks associated with healthcare provision. This entails creating and putting into practice strategies to enhance patient safety and the standard of care.
Mental Health Care
Medicare in Canada covers medically-assisted mental health treatment in addition to a disjointed network of ancillary services. Specialty psychiatric hospitals and general hospitals with mental health beds offer hospital-based mental health services. The provincial and territorial governments provide various community mental health and addiction services, including case management, assistance for families and caregivers, community-based crisis services, and supportive housing. Private insurance or out-of-pocket payments are made to private psychologists. Psychologists who work for institutions with public funding are paid.
Primary care does not explicitly include mental health. However, several organizations and jurisdictions have attempted to coordinate or link primary care and mental health services. For instance, an intersectoral mental health plan was expanded in 2014 to integrate other mental health and primary care in Ontario, where it has existed since 2011.
Long Term care and social support
The Canada Health Act does not consider long-term care and end-of-life care performed in non-hospital settings and in the community to be covered. All P/T governments pay for these services through general taxes, although the scope differs between regions. There is a significant difference in the additional services, such as medical supplies, equipment, and home assistance. Still, all provinces offer some level of residential care and some mixed case management and nursing care for clients receiving home care. Many legal systems demand copayments.
Personal and the government pays for nursing care in long-term residential institutions. Additionally, financial aid based on financial need may be used to offset room and board expenses. Several jurisdictions have set minimal residence requirements for facility entry.
P/T government contracts with service providers or government stipends to patients to pay for their services are used to finance public support of home care. For instance, customers can buy their home-support services under British Columbia’s Support for Independent Living program.
Most of these expenditures are incurred in hospitals, where provinces and territories are in charge of providing palliative and end-of-life care (supported by Canadian Medicare). However, many offer some coverage for services received outside those contexts, such as medical care, nursing services, and drug coverage in hospices, nursing homes, and other settings.
The federal government introduced a bill to change the criminal law to allow qualified individuals to ask a doctor or nurse practitioner for medical help in dying in June 2016. Since then, P/T governments and medical organizations have established procedures and legal frameworks to let patients with terminal or irreparable diseases receive medical help in dying.
In 2012, it was estimated that more than 8 million Canadians gave unreimbursed assistance to those with social and health needs. Support varies by province and territory for informal carers, who are thought to provide 66% to 84% of care for the elderly. For instance, the Caregiver Benefit Program in Nova Scotia offers qualified carers and care users CAD 400 (USD 317) each month. Additionally, a few government initiatives include the Employment Insurance Compassionate Care Benefit and the Canada Caregiver Credit.
Major Reforms introduced
An initial report was created in 2019 by the Advisory Council on the Implementation of National Pharmacare, founded in 2018. If a nationwide program is implemented, it will represent the most significant increase in public spending and coverage since the introduction of Canadian Medicare. Efficiency is improved when the provinces and territories implement structural reforms. The most recent instance occurred in Saskatchewan in 2017 when a single provincial health authority took the place of the province’s 12 regional health authorities.
A national tendency toward increased administrative centralization is reflected in this endeavor. Similarly, Manitoba created Shared Health as a single provincial agency to centralize some clinical and administrative functions as part of an ongoing reform initiative. The Ontario government plans to combine several regional arm’s-length organizations with the 14 subprovincial health authorities, known as Local Health Integration Networks, which manage and provide healthcare to their local populations, in 2019.
