Canada's Health Care System

How Health Care Services are Delivered

Canada's publicly funded health care system is best described as an interlocking set of ten provincial and three territorial health insurance plans. Known to Canadians as "medicare," the system provides access to universal, comprehensive coverage for medically necessary hospital and physician services. These services are administered and delivered by the provincial and territorial (i.e., state or regional) governments, and are provided free of charge. The provincial and territorial governments fund health care services with assistance from the federal (i.e., national) government.

In order to receive their full allocation of federal funding for health care, the provincial and territorial health insurance plans must meet five criteria -- comprehensiveness, universality, portability, accessibility and public administration -- that are provided in the federal government's Canada Health Act. In addition to setting and administering the Canada Health Act and providing funding, the federal government provides direct delivery of health care services to specific groups (e.g., First Nations people living on reserves; Inuit; serving members of the Canadian Forces and the Royal Canadian Mounted Police; eligible veterans). Many other organizations and groups, including health professional associations and accreditation, education, research and voluntary organizations, contribute to health care in Canada.

The responsibility for Aboriginal (First Nations people and Inuit) health services is shared by the federal, provincial and territorial governments, and Aboriginal organizations. The responsibility for public health is also shared. The federal Public Health Agency of Canada acts as a focal point for disease prevention and control, and for emergency response to infectious diseases; however public health services are generally delivered at the provincial/ territorial and local levels.

Ask a Canadian for a defining characteristic unique to Canada and invariably, even with [its] broad regional diversity, mention will be made of the country's publicly funded, universally accessible health care system. Medicare is often defined as a core value of our society.

Klatt, Understanding, 2000, p. 2

What Happens First (Primary Health Care Services)

When Canadians need health care, they generally contact a primary health care professional, who could be a family doctor, nurse, nurse practitioner, physiotherapist, pharmacist, etc., often working in a team of health care professionals. Services provided at the first point of contact with the health care system are known as primary health care services and they form the foundation of the health care system.

In general, primary health care serves a dual function. First, it provides direct provision of first-contact health care services. Second, it coordinates patients' health care services to ensure continuity of care and ease of movement across the health care system when more specialized services are needed (e.g., from specialists or in hospitals).

Primary health care services often include prevention and treatment of common diseases and injuries; basic emergency services; referrals to and coordination with other levels of care, such as hospital and specialist care; primary mental health care; palliative and end-of-life care; health promotion; healthy child development; primary maternity care; and rehabilitation services.

Doctors in private practice are generally paid through fee-for-service schedules negotiated between each provincial and territorial government and the medical associations in their respective jurisdictions. Those in other practice settings, such as clinics, community health centres and group practices, are more likely to be paid through an alternative payment scheme, such as salaries or a blended payment (e.g., fee-for-services plus incentives). Nurses and other health professionals are generally paid salaries that are negotiated between their unions and their employers.

When necessary, patients are referred to specialist services (medical specialist, allied health services, hospital admissions, diagnostic tests, prescription drug therapy, etc.).

Health Human Resources

Approximately 1.6 million people work in health care and social services in Canada, and include a mix of professionals in addition to nurses and physicians. The health industry is the 3rd largest employer after manufacturing and the retail trade.* Health care providers may be regulated through their professional colleges or other bodies, or non-regulated; unionized or non-unionized; employed, self-employed or volunteer.

Most doctors work in independent or group practices, and are not employed by the government. Some work in community health centres, hospital-based group practices, primary health care teams or are affiliated with hospital out-patient departments.

Nurses are primarily employed in acute care institutions (hospitals); however, they also provide community health care, including home care and public health services.

Most dentists work in independent practices; in general, their services are not covered under the publicly funded health care system, except where in-hospital dental surgery is required.

Other health professionals include: optometrists; laboratory and medical technicians; therapists; speech language pathologists and audiologists; psychologists; pharmacists; public health inspectors, etc.

*This industry-based statistic includes all employees of the health sector, including health support staff, such as clerical or cleaning staff, and not just health professionals. The data used come from Statistics Canada's Survey of Employment, Payroll and Hours, which excludes self-employed health industry workers (those who own and operate their own practice).

The health industry can be defined in several ways using the North American Industrial Classification System; however, no matter which definition is used, the health industry remains the third largest employer in Canada, behind manufacturing and retail trade. Data from Statistics Canada's Labour Force Survey, which does include self-employed people, supports this finding.

What Happens Next (Secondary Services)

A patient may be referred for specialized care at a hospital, at a long-term care facility or in the community. The majority of Canadian hospitals are operated by community boards of trustees, voluntary organizations or municipalities. Hospitals are paid through annual, global budgets negotiated with the provincial and territorial ministries of health, or with a regional health authority or board.

Alternatively, health care services may be provided in the home or community (generally short-term care) and in institutions (mostly long-term and chronic care). For the most part, these services are not covered by the Canada Health Act; however, all the provinces and territories provide and pay for certain home care services. Regulation of these programs varies, as does the range of services. Referrals can be made by doctors, hospitals, community agencies, families and potential residents. Needs are assessed and services are coordinated to provide continuity of care and comprehensive care. Care is provided by a range of formal, informal (often family) and volunteer caregivers.

Short-term care, usually specialized nursing care, homemaker services and adult day care, is provided to people who are partially or totally incapacitated. For the most part, health care services provided in long-term institutions are paid for by the provincial and territorial governments, while room and board are paid for by the individual; in some cases these payments are subsidized by the provincial and territorial governments. The federal department of Veterans Affairs Canada provides home care services to certain veterans when such services are not available through their province or territory. As well, the federal government provides home care services to First Nations people living on reserves and to Inuit in certain communities.

Palliative care is delivered in a variety of settings, such as hospitals or long-term care facilities, hospices, in the community and at home. Palliative care for those nearing death includes medical and emotional support, pain and symptom management, help with community services and programs, and bereavement counselling.

Additional (Supplementary) Services

The provinces and territories provide coverage to certain people (e.g., seniors, children and social assistance recipients) for health services that are not generally covered under the publicly funded health care system. These supplementary health benefits often include prescription drugs, dental care, vision care, medical equipment and appliances (prostheses, wheelchairs, etc.), independent living and the services of other health professionals, such as podiatrists and chiropractors. The level of coverage varies across the country.

Those who do not qualify for supplementary benefits under government plans pay for these services with individual, out-ofpocket payments or through private health insurance plans. Many Canadians, either through their employers or on their own, are covered by private health insurance and the level of service provided varies according to the plan purchased.

Trends/Changes in Health Care

The Canadian health care system has come under stress in recent years, due to a number of factors, including changes in the way services are delivered, fiscal constraints, the aging of the baby boom generation and the high cost of new technology. These factors are expected to continue in the future.

Since publicly funded health care began in Canada, health care services and the way they are delivered have changed from a reliance on hospitals and doctors to alternative care in clinics, primary health care centres, community health centres and home care; treatment using medical equipment and drugs; and public health interventions.

The number of acute-care hospitals and acute-care hospital beds decreased from 1995 to 2000. Medical advances have led to more procedures being done on an out-patient basis, and to a rise in the number of day surgeries. During this time, the number of nights Canadians spent in acute-care hospitals fell by 10%. Post-acute or hospital alternative services provided in the home and community have grown, with reforms such as hospital consolidation, less time spent in hospitals, growth in day surgery, etc.

Other reforms have focused on primary health care delivery, including setting up more community primary health care centres that provide services around-the-clock; creating primary health care teams; placing greater emphasis on promoting health, preventing illness and injury, and managing chronic diseases; increasing coordination and integration of comprehensive health services; and improving the work environments of primary health care providers.

When we first started debating Medicare 40 years ago, "medically necessary" health care could be summed up in two words: hospitals and doctors. Today, hospital and physician services account for less than half of the total cost of the system. ... In short, the practice of health care has evolved.

Canada. Commission, Shape the Future, 2002, p. 2

Coordinated primary health care teams include family doctors, nurses, nurse practitioners and other health professionals, and provide a broad range of primary health care services. These team members can vary according to the needs of the community they serve, and provincial and territorial priorities. This team approach, along with the introduction of medical telephone call centres (telehealth), reduces the use of emergency units by providing advice and after-hours access to primary health care services.

Most provinces and territories have tried to control costs and improve delivery by decentralizing decision making on health care delivery to the regional or local board level. Such regional authorities are managed by elected and/or appointed members who oversee hospitals, nursing homes, home care and public health services in their area.