@MAINHEADING = Preface



@MAINHEADING = Preface

@BODY TEXT - NVJ = Many Canadians are familiar with the story of the blind men and the elephant. For those people who are not, the story is about seven blind men who encounter an elephant for the first time. These seven men arranged themselves in a circle around the elephant, and then each stepped forward and felt a different part of the elephant. After this, each person believed they knew what an elephant looked like. Yet, not one of them had an accurate picture of the whole elephant.

@BODY TEXT - NVJ = The Canadian health care system is very much like an elephant. It is large and made up of many connecting parts. Some parts are closely connected to other parts and some are very loosely connected to each other. These parts however make up a whole system, and the whole is greater than the parts. And, just as elephant sightings are not routine in Canada, many services provided by the Canadian health care system are not commonly needed by every individual Canadian. Indeed, because of its size and complexity, the Canadian health care system tends to be only partly understood.

@BODY TEXT - NVJ = This book was written to help Canadians know more about their health care system. It is a snapshot picture only, showing the most important parts and connections between these parts. The chapters that follow were written voluntarily by a variety of Canadians, with experience gained from the Alberta scene, who are willing to share their knowledge and views of the health care system.

This booklet is believed to be a first of its kind about the Canadian health care system. All the authors hope you gain much insight from it.

Donna M. Wilson

Editor

@CHAPTERNUMBER = Chapter 1

@MAINHEADING = History of the Canadian Health Care System

@AUTHORNAME = Meluccia M. Di Marco and Janet L. Storch

One of the most significant questions about the Canadian health care system is “Why was it developed”? Following closely is the question “How was it developed”? Understanding how the system took shape is critical to understanding it’s strengths, as well as it’s challenges. The purpose of this chapter is to outline the evolution of the Canadian health care system; that is, how and why it developed.

Health care systems throughout the world are profoundly influenced by cultural, social, economic, political and geographic realities. So, too, the Canadian health care system has been shaped by a unique combination of these factors. Of particular note in Canada are the social values of Canadians. These values have been immensely important for developing a health care system designed for the common good. These values and circumstances can be divided into three major eras.

@MINORHEADING = Early Canada

Explorers who came to North America after the late fifteenth century were soon followed by settlers in the New World with one common goal - a more prosperous life (Baumgart, 1992). The colonists also brought with them a wide range of infectious diseases and, with poor sanitation and other health risks, these diseases flourished in mass epidemics. The first major health initiatives, which occurred well before Confederation in 1867, were public health boards, public health laws, and quarantine practices aimed at controlling the spread of infectious diseases. There was a tendency, however, to react to the crisis of the day. Public health measures lapsed whenever epidemics subsided.

Early settlers were self-reliant in providing for the necessities of life. With little or no government in place, it was generally expected that what government there was would be limited to a few essential services, such as care of the insane, the lepers, the foundlings (orphans); and, as indicated, to public health measures for handling epidemics (Storch & Meilicke, 1994). In the period before Confederation, social problems were seen as problems for families, the church, or the local community (Guest, 1985).

The events leading to Confederation served to build a country and with it a federal-provincial partnership in health care. Of major importance was the threat that the United States would control all of North America (Colombo, 1994). Rapid growth of colonies and major trade problems between them and other nations also served to make visionaries, like Sir John A. Macdonald, recognize a need for a coalition - in particular, a federation of existing Canadian colonies (Colombo, 1994). In 1867, the British North America Act (BNA Act or Constitution Act) was developed and signed. It created a nation of widely dispersed and independent regions, a dominion of sorts. The BNA Act also set out federal and provincial responsibilities that would become major factors in the organization and control of health care. At that time, only a few responsibilities were assigned in Section 91 to the newly created federal government (i.e. taxes, census and statistics, quarantine, criminal law, marine hospitals, and the care of aboriginal persons). In Section 92, provincial governments were assigned the establishment and management of hospitals, asylums and charities, and the responsibility to attend to >other matters of local or private nature in the province’. Health care services, such as they were, were usually delivered by private for-profit or not-for-profit charitable groups, with provincial governments taking a minimal role in health care.

@MINORHEADING = Middle Years

Between Confederation in 1867 and until the end of World War II in 1945 many developments occurred which would affect the design of a future health care system in Canada. Infections and untreatable injuries still prematurely claimed the majority of lives - although public health measures began to have a major effect on preventing deaths by reducing the breeding grounds for disease and the spread of infections (Baumgart, 1992). Until the mid-1950’s the majority of deaths in Canada were because of acute, largely preventable, but also untreatable illnesses (Statistics Canada, 1991). Tuberculosis, for example, was the leading cause of death in Canada until the 1920’s.

During this period, industrialization and the subsequent growth of cities created additional problems. The close “family” and small community concept began to change as a result of this migration and the social disruption arising from two World Wars (Guest, 1985). The shift to the city required, and resulted in, a more organized approach to health and social services. Families, churches, and communities could not adequately help needy people. Many large-scale voluntary associations and organizations were subsequently developed in the early 1900s. Some of these organizations are still active in Canada today, for example: Victorian Order of Nurses, Red Cross, Canadian Mental Health Association, and Children’s Aid societies.

Municipal governments also attempted to meet the needs of the poor and destitute, and increasingly the middle classes, by establishing insurance programs and other plans for private doctors and local hospitals. Provincial governments were only involved to a modest degree, as they did not have enough tax monies to support major programs. The federal government, however, began to assist in the provision of health and social services. The Roaring 20’s, a time of prosperity, was significant in the federal government’s ability to assist. In 1927 the Old Age Pension was developed, although many thought it would discourage thrift and self-reliance (Storch & Meilicke, 1994). Other short-term health and social programs were also initiated then by the federal government.

In the mid-1930s, a dispute arose over the right of the federal government to be involved in any area of social programming. To settle this matter a constitutional amendment was passed to enable the federal government to establish Unemployment Insurance (Taylor, 1987). Shortly after, the federal government began to plan for long range policy and program development in the whole area of social security. Many influences of the time brought about this belief in government intervention, in particular: the development of international statements on human rights and freedoms, the beginnings of other health and social programs in other countries, and the Great Depression.

The Depression of the 1930’s had a particularly important impact in Canada. People across Canada, and in all levels of government, came to recognize that misfortune could happen, and happen through no fault of their own (Guest, 1985). Furthermore, getting help when ill could be costly and therefore out of reach of many people. Charitable organizations and insurance plans, which had begun to allow more people to have access to health care, simply did not serve the majority of people. Most physicians, other health providers, and hospital services were private. A fee was charged to users. Also during this time, penicillin and other scientific advances in health care began to introduce additional costs and more interest in health care. The discovery of penicillin and other examples of the promise of science in health care, in particular, would become very important after 1945.

@MINORHEADING = Post World War II

The year 1945 marked the beginning of tremendous social and economic change, from which our current health insurance or Medicare program emerged. Increased diagnostic and therapeutic capabilities in health care assisted also in creating a perceived need for a more organized, and humane, approach to health care provision. The rapid and continued growth of scientific medicine and other developments within the health care field, which shifted health care from the home and community to the hospital, would later have major and largely unforseen implications for any subsequent programming. The period between the mid-1940s and 1972, in particular, was a time of rapid development of health care programs. Commissions and legislation, many of which are detailed in the Appendix, were primarily important for initiating change.

Prior to Medicare, Canadians paid for and inconsistently received health and medical services. There grew to be a bewildering number of insurance plans, none of which guaranteed protection from financial disaster as a result of a major illness. The wealthy could afford to pay for health services, and the poor were given some level of care at no cost through charitable organizations (Baumgart, 1992). The working, middle classes did not fit into either of these groups. The idea of health insurance strongly appealed to them (Baumgart, 1992).

In January 1947 the Saskatchewan government launched the “first universal (insurance) program in North America providing hospital care to all residents of the province regardless of means” (Baumgart, 1992, p. 29). British Columbia (BC), Alberta, and Newfoundland soon followed by creating similar provincial plans. All plans were based on a collection of premiums or taxes. In April of 1957 the federal government then passed the Hospital Insurance and Diagnostic Services Act (Taylor, 1987). The Act indicated that the federal government would give federal grants to provinces where hospital services had been made available to residents under uniform conditions and terms (Roy, Williams & Dickens, 1994). Five provinces joined immediately (BC, Alberta, Saskatchewan, Manitoba and Newfoundland), and all others followed by 1961. Although hospital care became available without major financial barriers to most Canadians, care by physicians did not.

Again leading the way, in 1962, Saskatchewan passed the Saskatchewan Medical Care Insurance Act. The Act covered physician and surgeon services, despite their opposition to such a program (Baumgart, 1992). A 1964 Royal Commission lead by Justice Emmett Hall recommended that “strong federal government leadership and financial support for medical care become a reality” (Shah, 1994, p. 287). Furthermore, Hall recommended against means testing, and subsidizing the poor so they could purchase insurance. Instead, he recommended that it would be desirable and socially acceptable to have a universal health care program for all Canadians. The federal government then passed the Medical Care Insurance Bill in 1966 (Roy et al., 1994). Alberta and Quebec were opposed to this Act, indicating that it interfered with provincial priorities (Baumgart, 1992). The Act promised federal grants to provinces that provided comprehensive, universal, publicly administered and non-profit, portable coverage of hospital and medical expenses (Roy et al., 1994). It took until 1972 for all provinces and territories to join (Roy et al., 1994; Taylor, 1987).

The 1957 Hospital Insurance Act and the 1966 Medical Insurance Act dealt primarily with federal transfers of money to provinces if certain principles were upheld. In fact, the arrangement was roughly a 50/50 sharing of costs. It is no surprise that following these Acts, there was a proliferation of public hospitals and health care services across Canada. In 1977, in response to rapidly increasing health care expenditures and a recession, the federal government passed the Federal Provincial Fiscal Arrangements and Established Programs Act (Roy et al., 1994). This Act replaced federal cost sharing with block transfers and grant payments to provinces, thus leading the way for decreased federal payments. Following this, extra billing (whereby patients had to pay some of their health care bill) became an issue. Other political, economic, and public pressures with respect to the perceived erosion of an already popular Medicare system in Canada led to the Canada Health Act.

The Canada Health Act (see copy in Appendix A at the back of this book) is an amalgamation of the previous 1957 and 1966 Acts, but with a few major changes. First, it affirmed an insurance basis to health care. Second, it reaffirmed and strengthened the principles of universality, portability, comprehensiveness, and public administration. Most significantly, it added a fifth criterion - that being accessibility. Accessibility outlaws costs being passed on to consumers through hospital user charges or extra-billing by physicians (Baumgart, 1992). Finally, “it gave the federal government the power to levy financial penalties (on a dollar per dollar basis) against provinces and territories failing to comply with these five principles” (Baumgart, 1992, p. 31). Despite opposition from some provinces and physician groups, by 1987 all provinces were following these principles.

Canadians at last had the security of publicly funded, good quality, comprehensive health care. Access to health care for all Canadians supported a strong social value of equality, in addition, it suited the economic and political climate of Canada at that time. Equality necessitated sharing, or the distribution of wealth to those less fortunate, for the common good. Canadians did not, however, have a single national health care system. Each province and territory was, and still is, able to define and provide health care within the broad criteria of the Canada Health Act (Roy et al., 1994; Shaw, 1994). Some differences in provincial health care plans across the country have emerged and, given the current climate of change, these differences are likely to increase over time. Nor has the issue of paying for health care gone away.

Since 1984 the federal government, again in response to fiscal realities, has taken steps to cut back transfers to provinces. The most recent development in 1995 is C-76, the Canada Health and Social Transfer Act. This Bill, now under consideration, would combine separate transfers for health and other social services into one. While this single transfer would give provinces greater flexibility in designing and paying for social services, at the same time it is expected that the total amount of transfer will be less.

@MINORHEADING = Conclusion

This chapter has traced the development of a national health care insurance program through three major eras. The first era was pre-Confederation, when few structures or governing mechanisms existed to deal with the primary health problem of the day, infections. In the second era, post-Confederation and through the two World Wars, major social changes contributed to the perception that governments should assume a social role. In the third era, the current national plan for health care emerged, was challenged by extra-billing, and was met by a strengthened national program as a result of the 1984 Canada Health Act. Through Medicare’s long development phase, the Canadian people have come to appreciate and acknowledge what Canada has become - a “safe, liveable community” and “a kinder, gentler society” (Chretien, 1995).

@MINORHEADING = References

@REFERENCES = Baumgart, A.J. (1992). Evolution of the health care system. In A.J. Baumgart & J. Larsen (Eds.). Canadian nursing faces the future (2nd ed., pp. 23-41). Toronto: Mosby Yearbook.

@REFERENCES = Chretien, J. (1995, April 6). Speech by Prime Minister Jean Chretien to the American Society of Newspaper Editors. Health Canada: Unpublished.

@REFERENCES = Colombo, J.R. (1994). Canadian history. In The 1995 Canadian Global Almanac (pp. 88-102). Toronto: McMillan Canada.

@REFERENCES = Guest, D. (1985). The emergence of social security in Canada (2nd ed.). Vancouver: University of British Columbia Press.

@REFERENCES = Roy, D.J., Williams, J.R., & Dickens, B.M. (1994). Bioethics in Canada. Scarborough: Prentice Hall Canada.

@REFERENCES = Shah, C.P. (1994). Public health and preventive medicine in Canada (3rd ed.). Toronto: The University of Toronto Press.

@REFERENCES = Statistics Canada. (1991). Canada yearbook 1992. Ottawa: Author.

@REFERENCES = Storch, J.L., & Meilicke, C.A. (1994). Political, social, and economic forces shaping the health care system. In J.M. Hibberd & M.E. Kyle (Eds.), Nursing management in Canada (pp. 19-36). Toronto: W.B. Saunders.

@REFERENCES = Taylor, M.G. (1987). Health insurance and Canadian public policy: The seven decisions that created the Canadian health insurance system (2nd ed.). Montreal: McGill-Queen’s University Press.

@MINORHEADING = Appendix

Major Canadian Health Legislation and Developments

@MULTCOLLEFT = Name and Year

@MULTCOLRT = Intent with Respect to Health

@MULTCOLLEFT = British North America Act (1867)

@MULTCOLRT = delineated federal and provincial government responsibilities.

@MULTCOLLEFT = Rural Municipality Act (1916)

@MULTCOLRT = allowed any rural Saskatchewan municipality to collect taxes for general practitioner and public health services.

@MULTCOLLEFT = Employment and Social Insurance Act (1940)

@MULTCOLRT = affirmed provincial responsibility for health matters.

@MULTCOLLEFT = Saskatchewan Hospitalization Act (1947)

@MULTCOLRT = confirmed universal hospital insurance for Saskatchewan residents.

@MULTCOLLEFT = National Health Grants Program (1948)

@MULTCOLRT = provided funds for building hospitals across Canada.

@MULTCOLLEFT = Hospital Insurance and Diagnostic Services Act (1957)

@MULTCOLRT = ensured basic uniformity of coverage throughout Canada while leaving administrative methods to the provinces.

@MULTCOLLEFT = Saskatchewan Medical Care Insurance Act (1962)

@MULTCOLRT = ensured medical care insurance coverage for Saskatchewan residents based on four of the five health care principles.

@MULTCOLLEFT = Medical Care Act (1966)

@MULTCOLRT = 50/50 federal-provincial cost-sharing of medical costs if provincial plans met the “four points”.

@MULTCOLLEFT-NVJ = Established Programs Financing Act (EFPA) (1977)

@MULTCOLRT-NVJ = equal federal-provincial cost sharing of health care is replaced with provincial per capital block grant tied to 3 percent growth of Gross National Product (GDP).

@MULTCOLLEFT = Canada Health Act (1984)

@MULTCOLRT-NVJ = added fifth principle (accessibility), prohibiting extra-billing and user fees, added a penalty clause.

@MULTCOLLEFT = Bill C-69 (1990)

@MULTCOLRT-NVJ = froze EPFA for 3 years and tied growth to GDP minus 3 percent.

@MULTCOLLEFT = Bill C-70 (1991)

@MULTCOLRT-NVJ = froze EPFA for another 2 years.

@MULTCOLLEFT = Bill C-76 (1995)

@MULTCOLRT-NVJ = would combine federal-provincial social service transfers into one.

@CHAPTERNUMBER = Chapter 2

@MAINHEADING = Who Uses the Health Care System?

@AUTHORNAME = Herbert C. Northcott

It is hard to imagine that anybody would not become a user of the health care system, either at birth, or during school immunization programs, or at times of sickness or accident, or later in life when age begins to take its toll. The question then is not “Who uses the health care system?”, but rather “Who uses what aspect of the health care system at what time and for what reason”? This chapter will first discuss the various parts of the health care system and then turn to the question of use.

@MINORHEADING = Health Care System Overview

The health care system is made up of many parts, including facilities such as hospitals, community health centres, clinics, and nursing homes; health care workers such as doctors, dentists, optometrists, nurses, physical and occupational therapists, and chiropractors; and organizations or programs such as provincial medicare programs, the provincial Ministry of Health, Workers’ Compensation, home care, the federal government’s Department of Health, the Canadian Medical Association, the Red Cross, and transportation systems for disabled persons.

The health care system also includes pharmacists and pharmacies with their prescription drugs and non-prescription over-the-counter medicines; ambulance drivers and emergency medical technicians; medical laboratories and medical laboratory technicians; the makers of wheel chairs and artificial limbs; and agencies that are concerned with public health, the environment, and occupational safety. The latter help to provide us with pure water, clean air, uncontaminated food, safer cars and highways, safe working conditions, and so on. A recent addition to the health care system in some provinces, although not a new idea, is the nurse-midwife specializing in the delivery of babies, either at home or in the hospital (Burtch, 1994). Finally, research and education are also parts of the health care system. Research on health, illness and disability is conducted by government, by business, and in universities (with funding from both government and business) while the education of health care workers, planners and administrators takes place in universities and colleges.

Canada’s health care system offers different types of care, including; cure for illness, rehabilitation treatment following illness or injury or for the disabled, palliative care for persons who are dying (with an emphasis on making the dying person as comfortable as possible), preventative services to make illness or injury less likely, and health promotion to encourage healthy lifestyles and environments.

The Canadian health care system is described officially as comprehensive, accessible, universal, portable, and publicly administered. In everyday language, this means that a wide range of services (comprehensiveness) are made available without financial or other barriers to all residents (accessibility and universality) regardless of where you happen to be in Canada at the time you need care (portability). This system of health insurance and health care is publicly administered and publicly funded by government through tax revenues rather than by private business.

Nevertheless, there is room for private business to offer some health services, for example, health insurance for persons travelling outside of Canada, pharmacists selling over-the-counter remedies, and optometrists selling eye glasses and contact lenses. Furthermore, there is a so-called “alternative” health care system which operates largely outside of the publicly funded health care system. Skrabanek and McCormick (1990) divide alternative therapies into several categories including: (1) medication, for example, herbal remedies, homeopathy, and naturopathy; (2) manipulation, for example, osteopathy, chiropractic, acupuncture, acupressure, massage, and reflexology; (3) devices, such as ozone generators, negative ionizers, and “radionic” machines that are said to be capable of both diagnosing and treating diseases; (4) mind cure, for example, faith healing, meditation, and mental imaging (also known as visualization); and (5) magic. In addition, there are alternative diagnostic techniques such as iridology which involves the examination of the coloured part (iris) of the eye for the purpose of assessing the state of the various parts of the body each of which is thought to be reflected in a specific area of the iris. Finally, various systems of “folk medicine” exist in Canada, to some degree at least, including native healers, Ayurvedic medicine (from India), traditional Chinese medicine, and traditional health care practices from Latin America.

The mainstream and alternative health care systems have tended to be very critical of and very hostile towards each other. Nevertheless, increasingly these systems are described as “complementary” because patients often use both systems and practitioners increasingly offer therapies from both systems (Northcott, 1994). For example, a medical doctor might offer acupuncture or suggest mental imaging in addition to or instead of more >conventional’ therapy. Furthermore, patients may seek out an alternative therapist after seeing a medical doctor, or vice versa, go to a doctor after seeing an alternative practitioner. Some patients use both conventional and alternative therapies at the same time. It appears likely that these systems of health care will increasingly come together as the good in each is accepted and the ineffective or bad in each is discovered and discarded.

@MINORHEADING = Health Care System Use

The health care system, then, is made up of many parts and different people use different parts at different times in their lives. Overall, some 80-85 percent of Canadians visit a medical doctor at least once a year. Visits to a medical doctor often result in further use of the health care system. For example, a visit to a doctor often results in the use of a medical laboratory, the purchase of prescription medicine, and may also result in a visit to a clinic for x-rays or to a physiotherapist, and so on. Some 5 to 15 percent of the population visit a chiropractor each year and about 10 percent use alternative health care (Northcott, 1994). Finally, a little over 10 percent are hospitalized in any given year and 1 in 4 of these hospital patients are hospitalized more than once in the year (Johansen et al. 1994; Randhawa, 1993). Note that there is overlap in these figures, as the same person might visit a doctor, a chiropractor, an herbalist, and be hospitalized for a time, all in the course of the same year.

Various national surveys (for a review see Northcott, 1995) have shown that use varies by age and sex, and also depends on a person’s occupation, social class, ethnicity, lifestyle, environment, and disabilities.

@SUBHEADING = Age

With respect to age, and starting at the earliest age, most babies are born in the hospital (although home births may be increasing, they are relatively rare). In either case, health care practitioners almost always assist. Survival rates are excellent, with only 7 babies in 1000 dying in their first year of life in Canada (Population Reference Bureau, 1993). Of course, some of the babies who survive are born with health problems or become sick. Babies who have chronic, that is, long-lasting health problems, are heavy users of health care. Ironically, such use may be increasing as the survival rate for infants improves. In the past, premature or unhealthy babies were more likely to die. They are more likely to survive now because of improvements in health care, but this means that they add to the use of the health care system. In fact, on an individual per capita basis children under the age of one have as many health care expenses as do seniors (Alberta Health, 1993). Health care expenditures drop as children age, with the lowest expenditure being in the 5 to 14 age range (Alberta Health, 1993).

Older children primarily use the health care system for visits to the dentist or to the optometrist for eye glasses, and for the treatment of accidents or infectious diseases, such as chicken pox, flus or colds. Childhood illnesses are less common today than in the past because of improved living conditions and immunization. It follows, though, that check-ups and immunizations constitute an important way in which children use the health care system.

Adolescents and young adults tend to enjoy relatively good health, and are typically not heavy users of the health care system. The infectious diseases that used to kill so many young people in the past are, for the most part, no longer serious threats (although we should not develop a false sense of securityΧconsider that HIV/AIDS is an infectious disease and epidemics of new and/or old diseases remain possible). The chronic diseases that are more likely to affect Canadians today typically do not appear until later in life. Should a young adult need health care it is often because of an accident or for lifestyle reasons, such as alcohol and drug abuse or sexuality including birth control, pregnancy, abortion, sexually transmitted diseases, and so on. Finally, adolescence can be a difficult time in terms of adjusting to one’s rapidly changing body and social status. The pressures of trying to cope with the changes of adolescence and of dealing with interpersonal problems with parents, siblings, teachers, and peers can lead to the use of counselling, mental health services, and acute emergency and hospital services.

In middle age, certain diseases and conditions become more common. For example, heart disease and cancers occur more frequently and diseases such as diabetes, multiple sclerosis, thyroid problems, and so on often appear in the adult years. Given that these health problems are typically chronic and long-lasting rather than short-lived, use of the health care system tends to increase for individuals with such conditions.

In the later years of life, chronic diseases and conditions become even more likely and seniors as a group are typically the heaviest users of the health care system. Life expectancy in Canada is now about 81 years for women and 74 years for men (Population Reference Bureau, 1993). More and more people are surviving to old age, and are surviving diseases and conditions from which a person in the past was more likely to die. Consequently, use of the health care system tends to increase. Heart disease, cancers, and stroke are the major killers of older persons in Canada today and are significant causes of health system use prior to death. Further, deteriorating mental function is a major reason for the placement of seniors in nursing homes. Alzheimer’s Disease, for example, results in a slow deterioration of the brain and eventually results in death. Nevertheless, not all serious health problems in old age necessarily lead to death. Arthritis is a common condition in the later years that does not lead to death but may lead to significant use of the health care system.

While health problems and therefore use of the health care system tend to increase with age, one must be careful not to “blame” seniors for making substantial demands on the health care system. Heavy users of the health care system represent all ages. The premature baby, the child with cystic fibrosis, the suicidal adolescent, the young victim of a motor vehicle accident, the pregnant mom, the person dying of AIDS, the person with cancer, the senior with Alzheimer’s, all are relatively heavy users of the health care system. In other words, different age groups have differing health care needs and use the health care system in different ways and for different reasons.

@SUBHEADING = Gender

Use of the health care system varies not only by age but also by gender. It is ironic that while women tend to live longer than men, they tend to make more use of the health care system, even after taking pregnancy into account. It appears that women are sick more, have higher rates of disability, visit the doctor more and are more likely to be hospitalized (Clarke, 1990; Edginton, 1989). Furthermore, as a couple ages, the wife is likely to provide care for her usually somewhat older and perhaps aging and ailing husband. However, given that she is likely to live longer than him, when it is her turn to need care she is often already a widow and more likely, as a consequence, to seek assistance from the health care system because she does not have a spouse to take care of her.

@SUBHEADING = Work

The work we do also has its health consequences (see Bolaria & Dickinson, 1994, parts 8 & 9). Workers may be exposed to the risk of accident and injury on the job. For example, those employed in heavy industries such as agriculture, construction, forestry, mining and manufacturing, and in service occupations such as firefighting and police work, often face immediate risks. Even if injury does not actually occur while at work, illness may result later as a consequence of exposure to harmful substances on the job. For example, long-term exposure to various dusts in the air at the worksite may eventually lead to certain cancers. Furthermore, even the so-called “white collar” professional jobs have their risks. For example, health care workers are exposed to the risk of infectious disease, and teachers, social workers, and businesspersons all may experience work-related stress. In short, different jobs produce different health problems and lead to differential usage of the health care system.

@SUBHEADING = Social Class

Peoples’ occupations are closely related to their social class. Social class is typically defined in terms of what one does for a living, how much money one makes, and how much education was required to get the job in the first place. The idea of social class then represents a number of different things, including whether one does blue collar or white collar work, whether one is rich or poor, and whether one is “educated” or not. In combination, these factors are related to health and health care use. Generally speaking, the lower social classes have more sickness, disability, and a shorter life expectancy (Clarke, 1990; Edginton, 1989). They are therefore more likely to be users of the health care system. Nevertheless, the higher social classes (or at least the women in these classes) may make more use of health care for preventative purposes.

@SUBHEADING = Ethnicity

Different ethnic groups, like different families, may have unique susceptibilities to various health problems. While these susceptibilities may result from genetic inheritance, susceptibility is also a result of shared environments and lifestyles. For example, recent immigrants to Canada may bring with them diseases and susceptibilities that are characteristic of their country of origin. Furthermore, Canada’s native peoples continue to have different patterns of sickness than do non-native Canadians. Indeed, natives have a higher infant mortality rate, a shorter life expectancy, higher rates of infectious disease among the young, higher rates of disability, and different patterns of illness and death. Natives are more likely to be injured or to die from motor vehicle accidents and from violence, suicide, fires, drownings, and so on (Clarke, 1990; Edginton, 1989). Finally, alcohol and substance abuse are often problematic.

@SUBHEADING = Lifestyles

Lifestyles are related to health care use. Smoking, alcohol and drug abuse, drinking and driving, refusing to wear seatbelts or helmets when riding bicycles or motorcycles, failing to practice “safe sex,” over-eating, under-exercising, stress, high risk activities such as mountain climbing or skydiving, sports and exercise injuries, and so on all have their health risks and lead to use of the health care system. The weekend “warrior” and gardener often pay in health consequences and each in turn may end up in the doctor’s or physiotherapist’s office on Monday.

@SUBHEADING = Environments

Environments also affect our health and may lead to health care use. Air pollution affects persons with asthma and other respiratory problems, as does second-hand smoke at home or at work. Water quality affects health. Reports of “beaver fever” obtained from one’s local water supply illustrate the importance of pure water. A safe working environment, a happy home, a prosperous and supportive society are all essential to good health. Problems in any or all of these areas tend to lead to various health problems and corresponding health care use.

@SUBHEADING = Disability

Mental and physical disability exists for various reasons. Some are born with disabilities, some become disabled as a result of injury or disease, and some develop disabilities as a consequence of aging. About 13 percent of Canadians have a disability (Statistics Canada, 1993 and 1990; Statistics Canada and the Department of the Secretary of State, 1986). Disabilities of various kinds commonly lead to use of the health care system.

@SUBHEADING = Palliative Care

Finally, the dying (of all ages and not just the elderly) tend to use the health care system. Of course, some die quickly and make very little, if any, use of health care. Nevertheless, it is often the case that dying is a process that lasts for months and even years. During this time, the dying person typically makes heavy use of the health care system (Evans et al., 1989).

@MINORHEADING = Debating the Appropriateness of Care

One might ask whether or not it is appropriate to provide the dying with extensive health care. With rising health care costs and huge governmental deficits and debts, questions get raised as to what kinds of use and how much use is “appropriate”. Because patient, provider and payer all have different interestsΧfor example, the patient wants care, the provider wants to make a good income, the payer (government) wants to keep costs downΧthere is a great deal of debate about what constitutes appropriate use. In this often emotional debate, the patient is frequently accused of over-using the health care system, the provider is often accused of over-servicing (that is, providing more or more expensive services than are required), while government is often accused of underfunding the health care system.

At the same time, some patients may be criticized for not seeking health care when it is needed, some providers are criticized for denying needed health care, and government is criticized for spending too much on building new hospitals. In other words, there is no easy definition of the term “appropriate use”.

There have been attempts to reduce hospital utilization by shortening the length of stay for mothers giving birth, for example, or by providing more “day surgery.” As a result, there is evidence that the use of hospital services has tended to decline (Evans et al., 1989). Since 1987-88, in particular, hospital use has tended to decrease, even for the oldest patients (Randhawa, 1993). Perhaps in reaction to declining hospital use, there has been some indication of an increase in use of physicians’ services (Barer et al., 1989). Although this trend may now be on the decline as a result of capped medical budgets by provincial departments of health, there are many reasons for increased use. These include: an over-supply of doctors (Taylor, 1994), increasing numbers of other health care practitioners, an increase in the practice of “defensive” medicine by practitioners worried about being sued (Conklin, 1994), new medical technologies, increasing rates of survival of persons who might have otherwise died (resulting in more persons living with long-term chronic illnesses and disabilities), and the increase in the proportion of the population that is elderly.

In conclusion, we all use the health care system in different ways at different times of our lives. Canadians have been fortunate that comprehensive, high quality care has been available and affordable for some time now. However, affordability has become an issue from the governmental point of view. As the health care system is restructured, patterns of use will change accordingly. It is likely that the use of the most expensive parts of the health care system, that is, institutional care in hospitals and nursing homes, will continue to decrease and that use of less expensive care, such as home care, will increase. Hopefully, our health care needs will continue to be met effectively, efficiently, and affordably.

The author would like to acknowledge the assistance of Corrine Truman, Donna Wilson, and the anonymous reviewers in writing this chapter.

@MINORHEADING = References

@REFERENCES = Alberta Health. (1993). Alberta Health, 1992-93, Statistical supplement. Alberta health care insurance plan. Edmonton: Author.

@REFERENCES = Barer, M.L., Pulcins, I.R., Evans, R.G., Hertzman, D., Lomas, J., & Anderson, G.M. (1989). Trends in use of medical services by the elderly in British Columbia. Canadian Medical Association Journal, 141, 39-45.

@REFERENCES = Bolaria, B.S., & Dickinson, H.D. (Eds.). (1994). Health, illness, and health care in Canada (2nd ed.). Toronto: Harcourt Brace.

@REFERENCES = Burtch, B.E. (1994). Promoting midwifery, prosecuting midwives: The state and the midwifery movement in Canada. In B.S. Bolaria & H.D. Dickinson (Eds.), Health, illness, and health care in Canada (2nd ed., pp. 504-523). Toronto: Harcourt Brace.

@REFERENCES = Clarke, J.N. (1990). Health, illness, and medicine in Canada. Toronto: McClelland & Stewart.

@REFERENCES = Conklin, D.W. (1994). Health care: What can the United States and Canada learn from each other?" In J. Lemco (Ed.) National health care: Lessons for the United States and Canada, (pp.169-184). Ann Arbor: The University of Michigan Press.

@REFERENCES = Edginton, B. (1989) Health, disease and medicine in Canada: A sociological perspective. Toronto: Butterworths.

@REFERENCES = Evans, R.G., Barer, M.L., Hertzman, C., Anderson, G.M., Pulcins, I.R., & Lomas, J. (1989). The long good-bye: The great transformation of the British Columbia hospital system. Health Services Research, 24, 435-459.

@REFERENCES = Johansen, H.C., Nair, C., & Bond, J. (1994). Who goes to the hospital? An investigation of high users of hospital days. Health Reports, 6, 253-263.

@REFERENCES = Northcott, H.C. (1994). Alternative health care in Canada. In B.S. Bolaria & H.D. Dickinson (Eds.), Health, illness, and health care in Canada (2nd ed., pp. 487-503). Toronto: Harcourt Brace.

@REFERENCES = Northcott, H.C. (1995). Health status and health care in Canada: Contemporary issues. In B.S. Bolaria & H.D. Dickinson (Eds.), Health, illness, and health care in Canada (2nd ed., pp. 198-219). Toronto: Harcourt Brace.

@REFERENCES = Population Reference Bureau. (1993). 1993 World population data sheet. Washington, DC: Author.

@REFERENCES = Randhawa, J. (1993). Hospital morbidity, 1991-92. Health Reports, 5, 355-365.

@REFERENCES = Skrabanek, P., & McCormick, J. (1990). Follies and fallacies in medicine. Buffalo: Prometheus.

@REFERENCES = Statistics Canada. (1993). Adults with disabilities: Their employment and education characteristics, 1991. Health and activity limitation survey (cat. 82-554). Ottawa: Minister of Industry, Science, and Technology.

@REFERENCES = Statistics Canada. (1990). Highlights: Disabled persons in Canada, the health and activity limitation survey (cat. 82-602). Ottawa: Minister of Regional Industrial Expansion.

@REFERENCES = Statistics Canada and Department of the Secretary of State of Canada. (1986). Report of the Canadian health and disability survey 1983-84. Ottawa: Minister of Supply and Services.

@REFERENCES = Taylor, M.G. (1994). Insuring national health care. In J. Lemco (Ed.), National health care: Lessons for the United States and Canada (pp. 223-243). Ann Arbor: The University of Michigan Press.

@CHAPTERNUMBER = Chapter 3

@MAINHEADING = The Determinants of Health

@AUTHORNAME = Corrine Truman and Gregg Trueman

Take a minute to think about your own health and the health of your family and friends. What does it mean to be healthy? How do we stay healthy? If ill, how do we become healthy again? Finally, how do we optimize our health? These questions are important for getting people to think about health in general and their own health in particular. But what is health?

It is generally believed that health is the absence of disease or injury. In other words, we are healthy unless we are sick. This view of health has helped to form a health care system that is commonly said to be a system for the sick, one that focuses to a large extent on illness care. This belief of health has also served to limit attention and concern over maintaining health or maximizing health. As a result, health tends to be overlooked until we are ill.

In contrast, the World Health Organization (1986) described health as “a state of complete physical, mental, and social well-being not possible without peace, shelter, education, food, income, a healthy and sustainable physical environment, social justice, and equity”(p. 2). The World Health Organization focuses on health as a positive or good quality, and one that is determined by a complex interrelationship of economic, social and physical influences. This chapter will focus on the determinants of health, those things that are now believed to promote health.

@MINORHEADING = Measuring Health

It is important for many reasons to be healthy, but how is health measured? Most people can easily report whether they feel healthy or not. But measuring health is neither straight forward nor simple. Our traditional measures, morbidity (disease) and mortality (death) rates, do not capture the complexity of the World Health Organization description of health. Mortality and morbidity rates are, at best, crude indicators of a lack of health.

Most “health” research has focused on comparing and explaining differences in rates of morbidity and mortality between different population groups and nations. More recently, international researchers have begun to focus on identifying what it is that makes us healthy. The Canadian Institute for Advanced Research (CIAR) in Toronto has been collating this research and has undertaken research of their own into the determinants of health. Several broad categories or factors which influence or determine our health have been identified. Identifying these factors has lead us to understand health in an entirely new way. New ways of measuring health are certain to follow.

@MINORHEADING = The Determinants of Health

Determinants of health are commonly understood to be: (a) our social environment, (b) our physical environment, (c) our biological endowment, and (d) health care services (CIAR, 1991). This list points out a peculiarity of health - many of the determinants of health could be outside of our control! Another peculiarity of our time is that, for many Canadians, the use of medical and hospital services has become linked with health. The truth is that most factors that affect our health are outside of the formal health care system. The Canadian Institute for Advanced Research (1991) has suggested that the social environment in which we live contributes approximately 50% to our level of health, our physical environment contributes approximately 15%, our biological endowment 10%, and health care services contribute, at best, only 25%.

@SUBHEADING = Social Environment and Health

Our social environment affects our health more than any other group of factors. Included in our social environment is our income, education, social support system, employment and national economic climate, and child development.

Personal income. Personal income has been shown to be one of the most powerful factors that affect our health (CIAR, 1991). The lower your income the shorter your life expectancy. The Canadian Institute for Advanced Research (1991) has found this relationship to be a continuous gradient and not a threshold. People in the top income bracket are therefore, as a rule, healthier than middle-income earners, and middle-income earners are healthier than low-income earners. One study, in particular, found men who were in the bottom 5% of earnings in the 20 year period before retirement were twice as likely to die by the age of 70 than men in the top 5% of earnings (Premier’s Council on Health Strategy, 1991). There is little doubt that being poor, for many reasons, is a major contributor to ill health.

Not only is personal income a powerful determinant of health, but the way in which income is distributed within a country also strongly affects health. People who live in a country in which there is a small gap between those in the top and bottom income groups (such as Japan and Sweden) tend to live longer than people who live in countries where there is a wider gap between the rich and poor (such as the U.S.A., Spain, the U.K., and France) (Population Health Resource Branch, 1994). In Canada the gap between top and bottom income groups is less than in the U.K. and U.S.A., but wider than in Japan (Population Health Resource Branch, 1994). The life expectancy in Canada and these other countries varies accordingly.

Education. Education is linked to income and to health in several ways. Education, as a rule, increases income, income security, and job satisfaction. Education also allows individuals to gain access to the information and services they need to keep themselves and their families healthy. For example, when nutritional information is available and used, it is expected that people will eat better and will reap the rewards of a better diet. But what is believed to be good in the diet changes over time, i.e. adults who grew up eating liver as a food item because it was “good for you”, now know liver should be eaten sparingly because of it’s high cholesterol content. Given the speed at which knowledge doubles, it is now understood that life long learning is vital to health. The importance of education is also supported by research that has found countries which have higher rates of literacy, especially of women, tend to have higher levels of health (World Bank, 1993). One outcome of education may be empowerment. Empowerment is when people recognize, promote, and enhance their ability to meet their own needs; solve their own problems; and mobilize the necessary resources in order to feel in control of their own lives (Gibson, 1991). Empowerment may also lead individuals to advocate for the good of other people.

Social support. People do not live in isolation. Having a supportive network of family and friends, and living in a good community are important contributors to our health. Family and friends provide basic housing and food, and they help look after us when ill or injured. They commonly provide mental and emotional support in times of distress. Families and friends also provide love on an ongoing basis, and they support individual lifestyle choices and changes.

Communities also affect our health. A health-oriented community provides people with a good environment in which to live and incentives to live in a way that promotes health. For example, if your community has good and well-used sports or recreational facilities, then it is likely that you will use those facilities, thus increasing your own level of physical activity and potential health. Supportive communities also provide opportunities for positive social interaction through libraries, schools, faith groups, recreation programs, clubs, etc.

Employment and economic climate. Our health is affected unfortunately by whether or not we are employed, and by our work place and the economic climate we live in. Unemployment, because it is so often associated with stress-related mental and physical problems, is often linked to poorer health. Mental and/or physical illnesses associated with unemployment are experienced not only by the unemployed individual, but also by their family and community. Individuals have been found to live longer in countries, like Japan, which have limited unemployment (CIAR, 1991).

Work can also be hazardous to health. A Swedish study found the organization of work, in particular the degree of authority and level of social support there, had a direct impact on the rate of cardiovascular disease (Johnson & Hall, 1988). In addition, our workplace and coworkers can have a direct impact on our lifestyle behaviours, i.e. our eating habits, our exercise patterns, and our decision to smoke, drink, take drugs or become involved in other risky behaviours. Our lifestyles are not completely under our control. However, since 1974 when Marc LaLonde identified the role that lifestyle plays in health, there has been a disturbing tendency to blame the individual for their illness or injury (i.e. blame the victim). It is not exactly correct to presume that people rationally and voluntarily choose an addiction to cigarettes or choose to consume alcohol to excess. Many lifestyle choices are a result of group pressures, a powerful kind of social conditioning. Lifestyle changes are difficult to make and our ability to sustain them is as much affected by our personal coping skills and our ability to adapt to stress, as by the values and common behaviours of our coworkers, friends, and families.

Child development. Prenatal and childhood conditions have a powerful effect on our health. For example, research indicates that the long term benefits for infants who were nursed at their mother’s breast include lower levels of obesity and blood cholesterol (Anholm, 1986). Prenatal development has also been shown to be strongly affected by poverty. Being born to a poor mother increases an infant’s chance of being born prematurely or with a low birth weight (LBW). LBW infants have a 40 times greater chance of dying during the first four weeks of life than do infants of normal weight. LBW infants have a greater prevalence of neurological/brain deficits, congenital abnormalities, and retarded development (Premier’s Council on Health Strategy, 1991). It is not surprising that countries, where there is a better health status overall, have commonly emphasized the well-being of women and children through effective social policies (World Bank, 1993).

@SUBHEADING = Physical Environment and Health

The air we breathe, the water we drink, and other elements of our immediate environment cannot help but affect our health. Polish health data, for example, linked poorer health with unclean and unsafe regions. In one particular area, designated as an ecological disaster, the infant mortality rate was consistently found to be the highest in Poland (CIAR, 1991).

Our physical environment also includes the risks we are exposed to at work, at home, and at play. Employment in certain lines of work can introduce injuries and lifelong disabilities, some of which may not be immediately apparent. Repetitive movement (e.g. back or arm) injuries, for example, can take months or years to develop. Second hand smoke and other chemical risks are common dangers many Canadians live with on a continual basis. It is not difficult to believe that reducing our exposure to hazardous wastes, and to air, food, and noise pollution will impact our health positively.

@SUBHEADING = Biological Endowment and Health

Our biological or genetic endowment also affects our health. For example, it has been estimated that 30% of infant deaths in the U.S.A. are due to genetic causes (CIAR, 1991). A strong genetic link has been found for certain diseases and conditions, such as diabetes and elevated blood cholesterol levels. Research will no doubt continue to show that the genes we inherit can predispose us to ill health. What will become even more important in the future will be the identification of environmental or social triggers that affect these genes (CIAR, 1991). Identifying and controlling these triggering agents may increasingly be used to preserve health.

@SUBHEADING = Health Care Services and Health

Many people return to health because of effective hospital and other health care services available to them. Illness care, however, is costly. Although the majority of money we spend on our health care system provides illness care to a relatively small number of people, most Canadians stay well as a result of publicly-funded immunization and other public health programs or services. Publicly-funded information campaigns have also helped to promote healthy lifestyle choices.

Now, more than ever before, the existing health care system in Canada is being questioned as to whether it provides value for the dollars spent. In particular, it is believed by many that additional spending on illness care services will do little to improve the health of our population (Rachlis & Kushner, 1994). Increased health care system spending may actually compromise spending in other areas, such as early childhood intervention and programs targeted to the poor - the very areas that we now know contribute more to improving a population’s health (CIAR, 1991). There seems to be a threshold for useful spending on illness care services. That threshold may have been reached in Canada, which means we need to focus more on retaining and enhancing health.

@MINORHEADING = Conclusion

Although this chapter has briefly identified and discussed a number of factors linked to health, it is evident that we need to know much more about what makes or keeps us healthy. It is also clear that a shift of emphasis (and spending) from illness care to health promotion is needed. For those people who are fearful of the shift because they believe hospitals will be beggared, the necessary shift is minimal. In fact, the Rainbow Report (1989) recommended a 1% shift of health care spending. Shifts in spending outside of the health care system also need to occur, particularly those which would eliminate poverty in Canada.

Before ending, it must be said that health is “worth it”. Health results in increased prosperity, because a healthy population is a major contributor to a vibrant economy. A healthy public needs less illness care. Health also results in increased well being of individuals and social stability of groups. Jake Epp, the Federal Minister of Health in 1986, reported that health is a basic and dynamic force in our daily lives. He stressed then that our system of health care as it presently exists does not deal adequately with the major health concerns of our time. Healthy public policies could remove barriers to good health. Healthy choices should become the accessible and easy choices.

@MINORHEADING = References

@REFERENCES = Anholm, P.C.H. (1986). Breastfeeding: A preventive approach to health care in infancy. Issues in Comprehensive Pediatric Nursing, 9(1), p. 1-10.

@REFERENCES = Canadian Institute for Advanced Research. (1991, August). The determinants of health (CIAR publication No. 5).Toronto.

@REFERENCES = Gibson, C. (1991). A concept analysis of empowerment. Journal of Advanced Nursing, 16(3), p. 354-61.

@REFERENCES = Johnson, J.V. & Hall, E.M. (1988). Job strain, work place social support and cardiovascular disease: A cross sectional study of a random sample of the Swedish working population, American Journal of Public Health, 78(10), 1336-42.

@REFERENCES = Lalonde, M. (1974). A new perspective on the health of Canadians. A working document. Ottawa: Minister of Supply and Services.

@REFERENCES = Premier’s Commission on Future Health Care for Albertans. (1989). The rainbow report. Edmonton: Author.

@REFERENCES = Premier’s Council on Health Strategy. (1991). Towards a strategic framework for optimizing health: Premier’s council on health strategy. Toronto: Author.

@REFERENCES = Population Health Resource Branch. (1994, June). Health impact assessment tool kit. B.C.: Ministry of Health.

@REFERENCES = Rachlis, M., & Kushner, C. (1994). Strong medicine. Toronto: Harper Collins.

@REFERENCES = World Bank. (1993). Investing in health. Oxford University: Author.

@REFERENCES = World Health Organization. (1986). The Ottawa charter for health promotion. Geneva: Author.

@CHAPTERNUMBER = Chapter 4

@MAINHEADING = Human Resources: The Backbone of Health Care

@AUTHORNAME = Cheryl Rehill and Douglas R. Wilson

Health care is big business. Alberta Health (1994a), for example, estimated that the health sector employs, directly or indirectly, about 8% of Alberta’s total work-force. Similar rates can be found across Canada. This means that approximately one in ten people work in the health industry. This chapter focuses on who works in the health care system, who employs health care workers, and current trends in health personnel.

@MINORHEADING = Who Works in the Health Care System?

There are a large variety of health occupations. For example, there are 47 different health occupations described in Alberta’s Inventory of Health Work-force (Alberta Health, 1994b). Health care workers can be broadly divided into four main groups; physicians, nurses, allied health professionals and support workers.

@SUBHEADING = Physicians

Often thought of as the gatekeepers of health care, physicians are the point of entry for most hospital and community services. Doctors provide services in many settings including hospitals, community health centres and walk-in clinics, continuing or long term care facilities, and private offices. In 1991, there were 60,559 civilian physicians registered to practice in Canada (Health Canada, 1993). Although this sounds like a large number, they are actually a small percentage of the health work-force. For example, in 1993 there were 4,571 physicians registered in Alberta, in comparison to a total of nearly 63,000 health workers (Alberta Health, 1994a). One statistic that is commonly used to judge physician supply is the physician to population ratio. In 1991, there were 467 Canadians per physician (Health Canada, 1993). The distribution of physicians varies considerably across Canada, as there are 1236 Canadians to one physician in the N.W.T. and only 430 Nova Scotians per physician (Health Canada, 1993).

Approximately 50% of physicians are general practitioners (often referred to as family physicians), and 50% are specialists. Most physicians derive their income from fees for performing specific services from provincial health insurance plans. For example, in 1993, the average fee for service payments to Alberta’s medical practitioners (GPs and specialists) was between $200,000 and $299,999 per year (Alberta Health, 1993). Approximately 50% of this income is used by physicians to pay their office and other practice expenses. There is also a minority of physicians who are paid totally or in part by salary. Hours of work and income vary, depending on whether the physician is a general practitioner (GP) or specialist, in a private (fee for service) or salaried practice, and their location of practice (i.e. urban or rural, and hospital or community clinic).

Physician supply has been the subject of increasingly careful analysis over the years (Sanmartin & Snidal, 1993). Following the introduction of Medicare in 1966, there was a planned expansion of Canadian medical schools (including 4 new schools) to address a perceived shortage of physicians. In the last 10 years, there has been concern that the growth in numbers of physicians was more rapid than the growth in Canada’s population. Between 1981 and 1991, the proportion of physicians per population went from 1 in 550 persons to 1 in 476 persons (Health Canada, 1993). Increasing health care costs are commonly thought to be because of an increased number of physicians, although a direct relationship has not been established.

The trend to increasing numbers of physicians is levelling off (Watanabe, 1994). Currently, the admissions to Canada’s 16 medical schools have been reduced by 10-15% and the immigration to Canada of physicians who are graduates of foreign medical schools has been severely limited. Until 1992, approximately 1700 new physicians graduated from Canadian universities each year, and approximately 400 foreign trained physicians were allowed to practice in Canada each year (Health Canada, 1993). Because of the time between medical school admission and entry to practice, it will take 5 to 10 years before the full effect of current reductions is clear. Other factors such as the increasing proportion of female physicians and the trend to shorter working hours, also affect the availability of physicians.

The mix or ratio of general practitioners to specialists in Canada of 50/50 is considered very satisfactory by international comparisons. In contrast, in the USA there is great concern about the low ratio of GPs to specialists of 20/80. In Canada there are specialties where shortages of physicians are predictable over the next few years, for example in general surgery, obstetrics, and gynaecology. Also, Canadian specialists as a group are significantly older (and thus closer to retirement) than general practitioners, so it is likely that there will be shortages of specialists in the future.

The distribution of physicians in rural/urban areas has not changed in recent years, with about 11% of physicians working in rural communities (those having a population of 10,000 people or less). Since about 25% of Canadians live in such communities, this indicates an undersupply of physicians there. Several provinces have programs in place to encourage physicians to set up practice and remain in rural Canada. Some provinces have also expanded the role of nurses and other health care professionals to meet health care needs in underserved areas.

@SUBHEADING = Nurses

There are approximately 230,000 registered nurses in Canada (Health Canada, 1993), which makes them the largest group of health care professionals. The majority of registered nurses work in hospitals. Many hospitals across Canada are currently downsizing, while community health care agencies are expanding. As a result, more nurses can be expected to work in non-hospital settings. Approximately 60% of nurses work full-time (Health Canada, 1993). Opportunities for full-time work will be reduced if current North American trends toward part-time, limited contract, and casual employment occur.

Nurses are usually paid a salary, with unionized staff nurse salaries ranging from approximately $18.00 to $22.00 per hour (depending on their educational level and years of service). The majority of Canadian nurses belong to a nursing union, although many new positions for nurses, for example those in private practice, do not involve union agreements. All registered nurses are regulated by their professional group, for example, the Alberta Association of Registered Nurses requires all registered nurses to continue to practice nursing on at least a part-time basis. Nurses who do not keep working must take a refresher course before practising again.

Nursing education programs offer preparation at either the diploma, baccalaureate, masters, or doctorate levels. These various education levels allow for nursing involvement in all areas and levels of the health care system. Given the increasing complexity of health care, and diversity of work setting and roles, the Canadian Nurses Association has taken steps to ensure all new nurses graduate from a 4-year baccalaureate program. Baccalaureate education allows nursing students to gain an excellent introductory level of health care knowledge, sharpen intellectual skills, increase their understanding and therefore participation in research, and prepares them to provide client-centred care in hospital and community settings. This educational background is essential today, as government budget reductions and changes in location of care have affected the nursing profession dramatically. Not only is the number of nurses in some provinces being reduced, as shown by recent Alberta data in Figure 1, but the roles and responsibilities of nurses across the country are being evaluated. In many instances, nurses are no longer performing traditional bedside care in hospitals, but are planning, coordinating, delegating, and evaluating care performed by other health care workers. In some cases, nurses are also delivering care that had been provided by other professionals (i.e. nurse midwives are delivering babies).

@SUBHEADING = Allied Health Professionals and Para-Professionals

In addition to physicians and nurses, there are numerous other persons who make very important contributions to health care, so numerous that it would be impossible to give information on them all. These persons have a wide range of educational preparation and roles within the health care system. To name a few, dentists and pharmacists have well established and distinctive professional roles. Other allied health professionals include dieticians, optometrists, psychologists, physiotherapists, occupational therapists and speech therapists (for speech, language and hearing problems). Para-professionals, those who do not require a university education, include licensed practical nurses, nurses aides and orderlies, medical laboratory and X-ray technologists, ambulance personnel (emergency paramedics), and many others. Educational levels for these health workers range from on-the-job training to doctorate degrees.

Allied health professionals and para-professionals are involved directly or indirectly with clients in community settings or hospitals. Allied health workers, in conjunction with physicians and nurses, make up multidisciplinary teams that deliver client/patient focused care to the public. Most allied health workers are salaried, although a number (i.e. dentists) receive a fee-for-service. Some operate outside the Medicare system, receiving no fees from public insurance plans or salaries from publicly funded health care organizations.

@SUBHEADING = Support Workers

Often referred to as “invisible health care workers” (CUPE, 1995), support personnel do not usually work directly with patients or clients yet they are an essential part of the health care system. In health care facilities porters, technical assistants, clerical staff, trades people, maintenance workers, food service and housekeeping personnel help to keep hospitals and other health care settings efficient, hygienic, safe and comfortable (CUPE, 1995). Support workers provide the labour and skills to make the health care system operate. For example, clerical and accounting staff and record keepers ensure that health information is organized, available and accurate. Support workers in hospitals and community settings may also include: volunteers, interpreters, and recreational therapy aides, to name a few. Support workers have diverse backgrounds and educational levels. Whether sterilizing instruments, admitting a patient to hospital, or visiting an elderly client, support workers provide a wide range of essential services necessary for a people-oriented health care system.

@MINORHEADING = Who Employs Health Care Workers?

It takes many people to provide health care. As indicated, health care workers include physicians, nurses, allied health professionals, and support workers. These groups find employment in a wide variety of institutional and community settings, and in either the public or private sector.

@SUBHEADING = Public Institutions

Publicly-funded acute care hospitals are the most common site of health employment in Canada. Important trends in hospital employment are occurring however. For example, as of December 31, 1993, there were 82 accredited hospitals in Alberta which provided over 13,000 beds for a wide range of treatments (Canadian Hospital Association, 1994). By 1996-97, the number of beds is expected to be reduced to 6500 as a result of budget reductions to hospitals and a shift to community care (Alberta Health, 1995).

Generally, there are three types of hospitals: community hospitals, regional or city general hospitals, and university teaching hospitals or health sciences centres. Hospitals are distinguished by the types of service provided, their size, and their connection with schools of medicine. Hospitals and other interconnected health care services are organized to provide primary, secondary or tertiary care. Primary care refers to first contact care with a physician (general practitioner), nurse or other health professional. Secondary care is provided by a referral from primary care provider to a medical specialist (internal medicine specialist, surgeon, psychiatrist, etc.), and tertiary care is complex care requiring the expertise of several specialist physicians and other health professionals.

Primary, secondary and tertiary care occurs in different settings. Community hospitals are generally small and rural, offering only primary or basic care. Regional or urban general hospitals are larger (more than 100 beds), and provide secondary as well as primary care. University teaching hospitals or health science centres provide tertiary as well as secondary care; are staffed mainly by medical specialists, and emphasize post-graduate level education and research. Health care personnel in all three types of acute care facilities may be involved in the assessment, diagnosis, and treatment of patients in various stages of illness.

Specialized care centres such as psychiatric hospitals, rehabilitation hospitals, cancer hospitals, childrens’ hospitals, and long-term care facilities also provide many additional employment settings in public facilities. Altogether, there may be as many job opportunities in these types of facilities, as there are in acute care hospitals across Canada.

@SUBHEADING = Private Institutions

The private sector provides employment for a small proportion of health care personnel. Private facilities may be owned or operated by for-profit businesses or by charitable, not-for-profit organizations. For example, in 1992-93 there were only 34 private nursing homes in Alberta (Alberta Health, 1993). There are a few specialized private treatment centres, which also employ some personnel, such as those offering cataract extraction, therapeutic abortion, cosmetic plastic surgery, or magnetic resonance imaging (MRI). In certain instances, these facilities are not truly “private”, as they receive both public funds (for medical services) and direct payments from clients, facility fees for example.

@SUBHEADING = Public Community Settings

Community health in the public sector, or “public health” does not aim its efforts to those who are sick. The objective of public health is to enhance the health and well being of Canadians through the development and delivery of health promotion, disease prevention, and community care programs, and to monitor the general state of health. This goal is reached by employing health care personnel in a variety of roles and settings.

Communicable disease control is a significant part of public health service. Immunizations, monitoring and tracking of communicable and non-communicable diseases, sexually transmitted disease information, recording, reporting, treatment and services pertaining to AIDS, tuberculosis, and appropriate provincial laboratory functions are all part of the public health mandate. Health care personnel in the public community sector also provide home care services; such as palliative care, IV therapy, aids for daily living, environmental health services, school health programs, family health services, or mental health services. The broad scope of public health objectives and services requires the skills of physicians, nurses, allied health professionals and support workers, all of whom contribute to reaching the goal of protecting and enhancing the health of the public.

@SUBHEADING = Private Community Settings

The private community sector also provides employment for a considerable number of health care workers. Private community agencies may be voluntary, non-profit/charitable, or for-profit organizations which receive government grants, contracts, or direct fees to provide their services. These agencies may also raise funds for education, research, or other projects. Private community agencies are “usually the product of the efforts of a few individuals who share a common concern or a common perspective on an issue” (Pringle, 1992, p. 615). The Victorian Order of Nurses (VON), Red Cross, Alzheimer Society of Canada and Meals-on Wheels are examples of private non-profit community agencies, all of which employ members of the health care work-force.

Large corporations may also employ health care personnel (such as doctors, occupational health nurses, physiotherapists) to ensure that the health of their employees is monitored and maintained. Pharmacists, dentists, and other private groups also employ a variety of staff to assist with providing their services. Numerous other health care workers have become entrepreneurs, starting their own businesses in the community.

@MINORHEADING = Current Trends in Health Manpower

As outlined, health care requires a large number of health care personnel to be effective. Recent government funding cutbacks and downsizing are major trends which have important implications for the nation’s health care work-force. Reductions in administrative staff, for example, may be considerable across the country. Alberta’s planned reduction in administrative staff over a three year period will be 44%, or approximately 724 full-time positions (Alberta Health, 1995). Salaries have also been lowered in some provinces, for example all public servants had a 5% wage reduction in Alberta in 1993-94 (Alberta Health, 1994a). A lack of employment openings now threatens many employees. The vacancy rate for all health occupations has declined, for example it has dropped in Alberta from 2.1% in 1992 to 1.6% in 1993 (Alberta Health, 1993). Alberta’s nurses, in particular, have experienced a severe decline in available positions as indicated by vacancy rates decreasing from 5.0% in 1990 to 1.2% in 1993 (Statistics Canada, 1993a, 1993b). Several health occupations reported zero vacancy rates in 1993. These low to zero vacancy rates combined with decreasing turnover rates (Alberta Health, 1993) have resulted in bleak prospects for health care workers, particularly those starting their careers.

In addition to downsizing, there is a trend towards “blurring” the margins between health care workers. Various provinces are approaching this in different ways. For example, the Alberta Health Workforce Rebalancing Committee (1994) has suggested an umbrella professions act, which would create generic health professionals. The roles and responsibilities of various types of health care workers would overlap. It is uncertain what effect this will have on quality of patient care, particularly since a major outcome of this would be the use of “cheaper” workers. At the same time, however, reductions in beds have raised the acuity or sickness level of patients in hospitals and other settings. While the proposed legislation has not been enacted, some related changes are already occurring. Aides and other support workers have begun to assume nursing roles and many disciplines are attempting to gain direct access to clients, thereby reducing the physicians’ gatekeeper role, for example, Albertans now have direct access to physiotherapists.

In addition to downsizing and redefining the roles and responsibilities of health professionals, another important trend which affects human resources is the shift from hospital-based care to community care. Only seriously ill and complex cases are admitted to hospital because of the reduction in hospital beds, shorter lengths of stay, and increasing out-patient procedures. At the same time, many patients are returning home within a few days after major surgery or not being admitted to hospital. Instead, they receive all their medical and nursing care in community health centres or the home. These changes require health care workers to upgrade or significantly change their knowledge and skills.

A final important trend influencing the health work-force is the progressive increase in the elderly population. An aging population is commonly expected to increase health care demands, and programs to maintain the independence of seniors will be essential.

@MINORHEADING = Summary

Learning who works in the health care system, who employs health care personnel, and the current trends in human resources, is an important step in becoming a well-informed consumer. As indicated, the health work-force includes physicians, registered nurses, allied health workers, and support personnel. Health care workers have many roles and responsibilities in institutional and community settings, both in the public and private sectors. Whether working in a hospital, doctor’s office, private nursing home, or self-employed, health care workers are involved in many different aspects of health care. Current trends which are important for Canadians to become familiar with, discuss and take action on are: downsizing, changes in professional roles and responsibilities, the shift from hospital to community-based care, and the growing aged population. These issues affect all of us, young and old alike.

@MINORHEADING = References

@REFERENCES = AARN. (1995). AARN membership summary. Unpublished manuscript.

@REFERENCES = Alberta Health. (1993). Alberta health 1992-1993: Statistical supplement, Alberta health care insurance plan. Edmonton: Author.

@REFERENCES = Alberta Health. (1994a, February). Alberta health: A three-year business plan. Edmonton: Author.

@REFERENCES = Alberta Health. (1994b). Inventory of health work-force in Alberta, 1993. Edmonton: Author.

@REFERENCES = Alberta Health (1995, February). Alberta health: A three-year business plan, 1995-96 to 1997-98. Edmonton: Author.

@REFERENCES = Alberta Health Workforce Rebalancing Committee. (1994). New directions for legislation regulating the health professions in Alberta. Unpublished manuscript.

@REFERENCES = Canadian Hospital Association. (1994). Guide to Canadian health care facilities: 1994-1995. Ottawa: Author.

@REFERENCES = Canadian Union of Public Employees. (1995). A statement regarding health reform in Alberta (Brochure). Edmonton: Author

@REFERENCES = Health Canada. (1993). Health personnel in Canada 1991. Ottawa: Author.

@REFERENCES = Pringle, D.M. & Roe, D.J. (1992). Voluntary community agencies: VON Canada as example. In A.J. Baumgart & J. Larsen (Eds.), Canadian nursing faces the future (2nd ed., pp. 611-626). St. Louis: Mosby-Year Book.

@REFERENCES = Sanmartin, C.A., & Snidal, L. (1993). Profile of Canadian physicians: Results of 1990 Physician Resource Questionnaire. Canadian Medical Association Journal, 149, 977-984.

@REFERENCES = Statistics Canada. (1993a). Industry and class of worker (1991 Census of Canada, Catalogue No. 93-326). Ottawa: Author.

@REFERENCES = Statistics Canada. (1993b). Registered nurses management data 1993. Ottawa: Author.

@REFERENCES = Watanabe, M. (1994). Physician resource planning: quest for answers. Clinical Investigative Medicine, 17, 256-267.

@CHAPTERNUMBER = Chapter 5

@MAINHEADING = Paying for Health Care

@AUTHORNAME = Herbert C. Northcott

In Canada, a person can go to the doctor or to the hospital and receive health care without receiving a bill. “Accessibility” is one of the principles under which Medicare was established. That is, the founders of Medicare believed that there should not be any barriers, financial or otherwise, to needed health care. In other words, it is believed that each person is entitled to health care even if that person cannot pay. Because patients today do not receive a bill for services received, there is a temptation to think that health care is “free,” which of course it is not. The question, then, is “Who pays for health care and how?” Furthermore, in these times of budgetary deficits and governmental debt, the question “Are we paying too much for health care?” is frequently raised. The following will focus on these two questions.

@MINORHEADING = Who Pays for Health Care?Before and After Medicare

Before Medicare, health care was something that had to be purchased in the same way that you would purchase groceries or tools. While health care was more or less essential, just as groceries and tools were essential, never-the-less when there was a need for services, one had to pay. After all, the health care practitioner was essentially a businessperson selling health care to those who could afford it. Of course, health care practitioners found it hard to deny services to those in need and often worked without pay because patients could not pay their bills. Eventually, other businesspersons began to offer hospital insurance and/or health care insurance to persons who could afford to pay the premiums. In time, the idea of providing care to all in need and paying for this care through “insurance” evolved into our current system of health care.

There is one fundamental difference today, however. Since Medicare, the insurance is offered by a public (government) agency rather than by private business. Just the same, many of the older private business aspects of health care still survive today and our present health care system is a mix of private and public sector involvement. In a private business model, the client pays directly for goods and services received. As noted above, this model is still very much a part of our health care system. One realizes this when buying medicine from the pharmacist, new eye glasses or contact lenses from the optometrist, vitamin supplements and herbal remedies from the health food store or when paying the dentist for filling a cavity. Private supplemental health insurance is also common (with premiums being a work benefit often paid for by employers).

In the public model, on the other hand, governments use tax dollars to pay for health care and the patient therefore does not have to pay directly for services. This public model, far more than the private model, has become very much a part of our health care system today. One realizes this when government pays for a person’s hospital care and other health care services provided by various health care practitioners such as doctors, physiotherapists, and chiropractors or when government pays for prescription drugs (as is done in some parts of the country or for certain groups such as the elderly).

So who does pay for health care? Given the combination of the private and public funding models, it should follow that both the private and public sectors pay for our existing health care system (see Figure 1). Indeed, about 72 percent of the total cost of health care in Canada is paid for by various levels of government, with provincial governments paying a larger share than the federal government. The remaining 28 percent of health care costs (Health Canada, 1994) are paid directly by the individual consumer, who purchases health care goods and services from private practitioners and businesses.

It should not be forgotten that the federal and provincial governments obtain the money that they need to pay for health care from taxes paid by individuals and businesses. In other words, we pay for health care when we pay our taxes. British Columbia and Alberta also charge health care premiums; however, whether you pay a premium or pay taxes, either way the money is collected by government and can be considered a tax to pay for health care.

If the federal and provincial governments did not collect taxes to pay for health care, our taxes could be reduced. Of course, each of us would then have to pay directly for our own health care. Would we be better off financially or better off in terms of health care or both? Comparisons with the United States, which is the only developed country that has not yet implemented a national health care system, suggest that not only would private health care cost more overall, it would fail to provide adequate health care for many (for a collection of essays on this topic, see Lemco, 1994). It is commonly reported, for example, that 37 million people in the USA have no access to health care, and a considerably larger number have limited access to health care.

Nevertheless, there is currently debate in Canada about how we should pay for our health care system (see, for example, Edginton, 1989). The federal government would like to pay less and consequently would like the provincial governments to pay more. The provinces tend to resent this “down-loading” as it is often called, and are faced with either raising taxes, or reducing health care system costs through “restructuring” and deinsuring and/or privatizing selected services. Both deinsuring and privatizing shift costs to the consumer and mean that individuals will have to again pay directly for services that have been covered under Medicare. Such changes might be viewed with some alarm. In the worst case scenario, one’s taxes would remain high even though there is reduced health care coverage and rising personal expenditures for health care.

There is also some discussion about the best way to pay health care providers. Nurses, for example, are paid a salary. Most doctors, on the other hand, are paid a fee for each service provided. In the United States, Health Maintenance Organizations (HMOs) pay practitioners a flat fee for each person under their care, regardless of the amount of care given (a system known as capitation, that is, payment per “capita” or per person rather than per service). Each payment system has its problems. When on salary, there is perhaps little financial incentive to work hard. Under fee-for-service, there is perhaps too much incentive to work hardΧto maximize one’s income by seeing too many patients in too short a time and by encouraging unnecessary visits and services. Under capitation, there is an increased incentive to do health promotion and disease prevention; after all, the practitioner gets paid even if the people under her/his care are healthy. However, under capitation, persons who are sick or at risk of becoming sick (e.g., the elderly) might find the practitioner unwilling to “sign them up,” or unwilling to provide expensive but necessary care.

As Figure 2 shows, total health care costs (paid by both government and private individuals) can be broken down into various components (Taylor, 1994). The single most expensive component of the health care system is the hospital. About 40 percent of all health care dollars go to pay for the costs of operating hospitals (most of which goes for salaries). The second biggest expense is the doctors who receive some 16 percent of health care spending. Prescription drugs, non-prescription over-the-counter drugs, and such things as eye glasses and hearing aids cost another 14 percent of health care funding. The costs of the administrative bureaucracy for the Medicare program are minimal, totalling just over 1 percent of all expenditures. The remaining funds (approximately 29%) are spent on public health, construction, research, home care, ambulances, and so on.

@MINORHEADING = Are We Paying Too Much for Health Care?

So how much does health care cost and does it cost too much? Canadians spend about 10 percent of the country’s total income (Gross Domestic Product) on health care (Health Canada, 1994). While this is substantially less than the United States, it is more than in any other industrialized country (Lemco, 1994). So are we spending too little, or too much, or just the right amount? The answer is not an easy one. Suppose you want to buy a car. How much should you spend on the car? You will probably answer that it depends first on how much money you have (or can comfortably borrow). Second, you will probably answer that it depends on both what you need (a safe and reliable vehicle) and want (the best!!). In the end you will weigh these different points and reach a decision. And if you are prudent and have limited dollars, you will probably buy a car that is adequate and affordable, although not quite the “best.” So it is with health care. The decision involves weighing what we can afford against what is desired. This decision is not done individually, but rather by policy makers acting on behalf of all Canadians. It follows that the decision is a political one (Culyer, 1988). This political decision is not easy. When someone is sick, they want good care, so that person or their family would argue for a relatively high level of funding. Further, health care providers tend to argue that government should spend more. After all, they have a vested interest in that their incomes and working conditions depend on government funding and they have a goal of saving lives despite the costs. However, individual taxpayers may complain of high taxes and businesses may argue that high taxes reduce consumer purchasing power while at the same time driving up the cost of producing goods and services. Policy makers have to balance all these competing demands. Excellent health care, high provider incomes, and low costs...it cannot be done!! And to make the decision even more difficult, the policy makers also have to allocate public dollars to areas other than health care. At this point, the crunch becomes apparent. If you visualize the governmental budget as a pie, then if the piece of the pie given to fund health care is increased in size, the piece of the pie available for funding education, or welfare, or day care must get smaller.

Alternatively, if the pieces of the pie spent on things other than health care increase in size, then there is pressure to reduce the amount spent on health care. This is in fact the situation in Canada at the present time. For some time now both federal and provincial levels of government have been spending more each year than they have been getting in revenues, and they have been borrowing to cover these annual deficits. This borrowing has resulted in substantial accumulated debt. Each year, interest payments must be made on these debts. As interest payments have increased, there is less and less money available for health care and other government sectors. Indeed, we now spend more in Canada on interest payments for governmental debts than we spend on the entire health care system!! (Northcott, 1993).

In other words, assuming that the federal and provincial governments were not in debt, and assuming current levels of government spending, then we could afford the health care system that we have and another one just like it. Not that we need another health care system, but my point is that government indebtedness is making it increasingly difficult for governments to pay for various social programs including health care. In short, there is not a health care funding crisis in Canada today so much as there is a debt crisis.

Given that there is a debt crisis, it is regrettably necessary to consider all possible ways to increase governmental revenues and/or reduce governmental spending. If deficits are not eliminated and debt loads brought under control, interest payments on the debt will continue to grow at the expense of funding for health care and other government programs. This conclusion is so inescapable that governments in Canada whether NDP, PC, or Liberal have all gotten on the deficit-reduction or elimination bandwagon. The argument then is that the present reductions in health care funding are necessary to guarantee the country’s ability to maintain the Medicare system in the long term. Some see a more sinister motivationΧbelieving that there is a movement to dismantle Medicare and indeed the entire social safety net.

@MINORHEADING = Reducing the Cost of Health Care

In an attempt to reduce budgetary deficits, governments are seeking ways to reduce the cost of health care. Many different strategies are being attempted or debated. Given that hospital care is the most expensive item, attempts are being made to reduce hospital costs by the following: reducing the amount of time that the typical patient stays in the hospital, increasing the amount of hospital treatment offered during the day (e.g. “day surgery” meaning that the patient goes home after surgery to recuperate instead of staying overnight in the hospital), reducing the number of hospital beds and therefore the number of staff (“downsizing”), and “rationalizing” or “restructuring” the hospital care system including closing some hospitals, redefining the role of others and altering relationships between hospitals (e.g. through regional coordination). Finally, a major attempt is being made to shift care from institutions like the hospital or nursing home to the patient’s own home. Government planners hope that more and more people will be cared for in their own homes, where care is usually cheaper.

The second most expensive item is physician incomes. Again, many different strategies are being attempted or debated to reduce costs in this area. First of all, physician fee schedules are negotiated between the medical profession and the government of each province, and governments have attempted to control costs by limiting increases to the fee schedules. Further, it has been argued that there are too many doctors and that restrictions be placed on medical school enrolments, the number of doctors allowed to immigrate to Canada from other countries, and the number of doctors allowed to practice in a given area within Canada (Taylor, 1994).

The third most expensive item is prescription drugs, other medicines, and health aids such as eye glasses and hearing aids. Perhaps because many of these expenses are already paid directly by the individual rather than by government, there has been less said about cost-saving in this area. Just the same, there have been several suggestions about reducing costs through using the cheapest form of a drug (generic drugs) even when the doctor prescribes a more expensive version, and deinsuring selected coverage (e.g. having people pay out of pocket for drugs or aids that have been previously covered).

It has also been argued that one strategy to reduce health care costs is to have people pay something out of their pockets each time they use an aspect of the health care system. These fees have been variously labelled as user fees, deterrent fees (that is, they are supposed to stop or reduce use), co-payments, insurance deductibles, direct billing and extra-billing. Those who favour such fees argue that they will reduce unnecessary, excessive, or frivolous use. Those who oppose such fees argue that the rich will not be discouraged from seeking care, whether necessary or unnecessary, while the poor, sick, and elderly will be hindered from seeking even necessary care (Northcott, 1994).

Health care rationing is another debated option. That is, one possibility for cost saving is to limit the number of services available to a population so that priorities are set and resources not spent on low priorities. Let me spell this out in its most objectionable form. It might be decided that all patients over the age of 70, for example, will not receive transplants nor any “heroic” attempts to prolong their lives. Seniors who are dying, after all, it might be argued, cost the health care system a great deal of money, money which could be saved or better spent. Personally, I have some trouble with this argument. It may make sense from a cost-savings point of view. But I worry about where the argument might lead. For example, as a person approaching 50 years of age, I worry that someone someday might decide that all people over the age of 45 who get sick should be dispatched quickly and cheaply!!

As has been pointed out above, Medicare does not currently pay for all health care costs. One way of reducing costs would be to reconsider two of the principles underlying Medicare, namely comprehensive coverage and universal coverage. Comprehensiveness refers to the range of services covered under Medicare. Deinsuring some of these services would certainly reduce Medicare costs, as governments would no longer have to pay for them. However, direct costs to the user would increase.

The ultimate deinsurance strategy would be to simply do away with Medicare altogether. Public funding and involvement would cease and health care would be “reprivatized,” that is, returned completely to the private sector. Very few patients, practitioners, and politicians today would suggest this. However, some have suggested that universal coverage be eliminated and that health care insurance be provided only for the most needy. In other words, all care for the financially better-off would be deinsured. The better-off would pay directly for care purchased from the private sector, while the poor would receive care from the public health care system. In a sense the rich would pay twice, once out of pocket for services purchased and a second time in taxes paid to fund the public system. The poor would not have to pay. However, some fear that the rich would have quicker access to better health care and that a bare minimum of care would be available to the poor. Such a system has been described as having two “tiers,” one for the rich and another for the poor.

@MINORHEADING = Summary

To sum up, the answer to the question “Who pays for the health care system?” is that we all do, both directly out of pocket and indirectly through taxes paid. The answer to the question “Is the health care system too expensive?” is: perhaps...depends...not necessarily. However, in these times of limited governmental revenues, budgetary deficits, and horrendous accumulated debts with huge annual interest charges, the answer is academic. Whether the health care system is too expensive or not, there is considerable pressure on governments to reduce health care spending. Hopefully, health care restructuring will result in each public health care dollar being better spent so that we will continue to get high quality health care at a reasonable and affordable price.

The author would like to acknowledge the assistance of Corrine Truman, Donna Wilson, and the anonymous reviewers in writing this chapter.

@MINORHEADING = References

@REFERENCES = Culyer, A.J. (1988). Health care expenditures in Canada: Myth and reality; past and future. Toronto: Canadian Tax Foundation.

@REFERENCES = Edginton, B. (1989). Health, disease and medicine in Canada: A sociological perspective. Toronto: Butterworths.

@REFERENCES = Health Canada. (1994). National health expenditures in Canada, 1975-1993. Ottawa: Author.

@REFERENCES = Lemco, J.(Ed.). (1994). National health care: Lessons for the United States and Canada. Ann Arbor: The University of Michigan Press.

@REFERENCES = Northcott, H.C. (1994). “Threats to Medicare: The financing, allocation, and utilization of health care in Canada.” In B.S. Bolaria & H.D. Dickinson (Eds.) Health, illness, and health care in Canada (2nd ed., pp. 65-82). Toronto: Harcourt Brace.

@REFERENCES = Northcott, H.C. (1993). “The politics of fiscal austerity and threats to medicare”. Health and Canadian society, 1, 347-366.

@REFERENCES = Taylor, M.G. (1994). “Insuring national health care.” In J. Lemco (Ed.), National healthcare: Lessons for the United States and Canada (pp. 223-243). Ann Arbor: The University of Michigan Press.

Additional author note: The “textbook” on the subject of health care funding has been written by Robert G. Evans. (1984). Strained mercy: The economics of Canadian health care. Toronto: Butterworths.

@CHAPTERNUMBER = Chapter 6

@MAINHEADING = The Role of Law

@AUTHORNAME = P. L. James

@MINORHEADING = Jurisdictional Framework

To understand the role of law in the Canadian health care system, one must first understand the roles of the federal and provincial governments. The Constitution Act (formerly called the British North America Act of 1867) granted the federal government exclusive jurisdiction over 29 subject areas (Section 91), while the provinces were granted exclusive jurisdiction over 16 subject areas (Section 92). Exclusive jurisdiction means that each level of government is only able to pass laws in the areas it has authority over. For example, only the federal government has the right to make banking laws, since banking is one of the 29 federal subject areas.

Among other things, the provinces were made responsible for “the establishment, maintenance and management of hospitals, asylums, (and) charities...in and for the province, other than marine hospitals” (Constitution Act, Section 92[7]), “property and civil rights,” (Constitution Act, Section 92[13] and “all matters of a merely local or private nature” (Constitution Act, Section 92[16]). These provisions give the provinces general authority over health care (i.e. the court ruled so in Schneider v. the Queen, 1982). Provinces are therefore able to pass laws that regulate health care professionals, hospitals, and other health facilities.

The provinces, however, do not have exclusive control over health and health care. The federal government also has a role (Schneider v. the Queen, 1982) which is based upon its Constitutional jurisdiction over spending, criminal law, and “laws for the Peace, Order and Good Government of Canada” (POGG). Each of these three areas is important.

For instance, the Canada Health Act(1984) is a law that has been enacted under the federal government’s spending power, and it is the means by which the federal government transfers funds to assist provinces with the costs of delivering health care services. Similarly, narcotics and other drugs are regulated by the federal government under their criminal law power. Under POGG, the federal government has the authority to make laws dealing with emergencies or matters of national concern (Hogg, 1985). This power could be used to deal with a health matter of national concern, for example a nation-wide epidemic. At this point, however, it is not entirely clear what limits there are on the federal government’s ability to make laws that affect health care delivery.

It has been generally settled that programs for the delivery of hospital and physician services fall under provincial control. Nevertheless, the federal government has played the major role in setting the terms and conditions of our Medicare system (i.e. hospital services and medical care). This role came about because of federal cash contributions to provinces (Hogg, 1985). All of the provinces were willing to accept the five conditions that are stipulated in the Canada Health Act (1984) in order to receive federal monies.

These shared-cost arrangements with the provinces have been increasingly difficult for the federal government to maintain. During the 1980s, Canada faced two serious economic recessions. Both the provincial and federal governments have been looking for ways to reduce expenditures. The federal government has steadily reduced the financial assistance given to the provinces to assist them with the delivery of education, social welfare and health care programmes. As federal transfer payments to the provinces continue to diminish, there will likely be a great deal of variation between wealthier and poorer provinces and territories, in the health care services that are provided.

As both levels of government attempt to reduce or shift health care costs, many Canadians are beginning to worry that they or their loved ones will not receive the health care they need and thought they were entitled to as Canadians. But, do Canadians have a right to health care?

@MINORHEADING = The Canadian Charter of Rights and Freedoms

In attempting to answer the question of whether there is a guaranteed right to health care in Canada today it is necessary to look to the Charter (1982). The Canadian Charter of Rights and Freedoms, as it is properly titled, defines basic rights guaranteed to all Canadians. These rights are also known as “entrenched” rights. They include, among others: freedom of religion, mobility rights, and the right to be free from arbitrary search and seizure. There is no specific provision in the Charter that guarantees a right to health care. Thus, one must look to other provisions in the Charter in order to determine whether a right to health care exists, most notably Sections 7 and 15. Section 7 guarantees the “right to life, liberty and security of the person” while Section 15 provides a guarantee of equality before and under the law. Section 7 and 15 are the most likely provisions that could be construed as providing Canadians with a legal entitlement to health care (Jackson, 1988). Some commentators suggest that the Charter does not guarantee a right to health care (Canadian Bar Association, 1994).

@SUBHEADING = Legislation

If the Charter does not guarantee a right to health care for all Canadians then any legal entitlement to health care must be found in either federal or provincial legislation. Quebec is the only province that has enacted provincial legislation that provides its citizens with a right to health care within circumscribed limits. Quebec residents are entitled to appropriate health services and social services within limits based upon the availability of human, material and financial resources. Other provinces merely list those services which are “medically required” and services may be added or delisted.

In terms of federal legislation, the Canada Health Act which replaced the preceding Medical Care Act and the Hospital Insurance and Diagnostic Services Act sets out 5 conditions, all of which must be adhered to by the provinces in order to qualify for the full transfer by the federal government. The five program criteria are: public administration, comprehensiveness, universality, portability, and accessibility. In addition to the program criteria, two enforcement provisions prohibit extra-billing by medical practitioners and user fees. Penalties may be a dollar-for-dollar reduction in transfer payments (of the amount a province permits in extra-billing or user charges) or, if the federal cabinet considers the violation to be serious, it may direct that a proportion of or all of the transfer payment be withheld from the offending province.

For the most part, these provisions have ensured that Canadians “will have access to medically required services and hospital services without financial or other barriers; that these services will be administered on a public, not-for-profit basis, and that no matter where they live in Canada they will be compensated for health care services inside or outside of Canada at the same rate as if the service had been provided in their province of residence” (Canadian Bar Association, 1994, p. 29-30).

Although the Canada Health Act has thus far ensured Canadian residents health care coverage, it is important to note that it does not guarantee health care. Provinces can decide whether they wish to comply with the five criteria or forego the federal contribution. Until recently, no province has been willing to risk losing federal funds but, as the contributions diminish, the principles of Medicare are eroding. For example, Ontario and Alberta reduced coverage to residents who obtain medical care outside the province. Senior citizens who spend their winters in the United States were primarily affected by this, and consider it to be a violation of the “portability” criterion of the Canada Health Act.

Delisting or deinsuring previously covered services is another issue upon which the federal government and certain provinces disagree. The Canada Health Act requires provinces to supply residents with “medically necessary” hospital services and “medically required” physician services. Provinces which are deinsuring procedures have asked the federal government to clarify what services it believes should be included in their health care insurance plans. Until recently, the federal government has refused to do so. However, in September 1995 the federal government announced that it considers abortion to be a medically necessary service, and will penalize provinces which do not pay the full cost of abortions (whether they are provided in a public hospital or private clinic).

Another concern expressed by the federal government has been the emergence of “facilities fees” for medical care. Facility fees are surcharges that are in addition to the fee paid to providers by Medicare. The Federal Minister of Health, in early 1995, stated that these fees constitute “user fees” which are prohibited under the Canada Health Act. She gave the provinces until October 15th, 1995 to eliminate these additional fees charged by private clinics, or risk reductions in transfer payments. Apart from Alberta, all of the provinces initially expressed a willingness to comply with this directive.

@MINORHEADING = Remedies

Given that there is no legally guaranteed right to health care in Canada today, can an individual who is denied access to health care service(s) challenge the decision?

@SUBHEADING = Violation of Charter Rights

Although the Canadian Charter of Rights and Freedoms (1982) does not specifically guarantee a right to health care when health is provided publicly by the government, the Charter does stipulate that health care must be provided to all persons in a fair and equitable manner. The most likely sections under which a Charter remedy may be sought are Sections 7 and 15. Section 7 guarantees “right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice”. Denial or restriction of access to medical care or treatment may violate one of the three rights listed in Section 7. If so, a court must then determine whether or not the denial or restriction has been determined in accordance with the principles of fundamental justice.

Fundamental justice has both a substantive and a procedural component requiring a decision-maker to consider all relevant factors and to make the decision in a fair manner. For example, every person needing a transplant cannot necessarily obtain one. However, each person who may be a transplant candidate is entitled to a fair assessment. Each person must be given an opportunity to be placed in the pool of potential recipients, providing that person meets certain criteria (criteria which must also be relevant and fair). A court reviewing the transplant decision would have to assess the process by which the decision had been made and whether the criteria on which the decision was based were appropriate. If the decision was made by a government body that took into account all relevant criteria and made the decision in a fair manner, it is likely the court challenge would be unsuccessful.

In the case of a challenge under Section 15 of the Charter, an applicant must show that he or she has been treated differently, or is part of an identifiable group that has been treated differently (for example, on the basis of a mental or physical disability, or any similar ground). The denial of a procedure to a smoker may therefore be judged to be explicitly discriminatory or discriminatory in its effect.

Even if a court finds that an individual’s rights have been violated, the court must also consider whether the infringement is justifiable under Section 1 of the Charter. Section 1 indicates that Charter rights may be “subject to such reasonable limits prescribed by law as can be justified in a free and democratic society.” This means there may be some restrictions of rights guaranteed under the Charter. A government may argue, for example, that access to health care has been denied because of a lack of resources. The Supreme Court has already suggested that this may not constitute a valid excuse (Schacter v. Canada, 1992).

Where the Charter does not apply, individuals may also challenge access decisions under federal and provincial human rights legislation that prohibits discrimination. In addition, individuals may initiate legal actions against individual health care providers.

@SUBHEADING = Actions in Tort and Contract

An individual may commence a legal action because they have been denied access to a particular service or procedure. Tort law deals with all areas of human conduct that may cause harm to other persons. Health care providers are most likely to be sued for being negligent. Negligence may include failing to provide appropriate care, or providing care that is below the expected legal  standard. Because of a lack of resource allocation lawsuits in Canada to date, it is not clear at the present time how valuable tort law will be for enforcing rights to health care (Caulfield, 1994). For example, few Canadians are successful in suing their physicians. In 1993, 1,220 legal actions were commenced against Canadian physicians. Only 81 of these legal actions went to trial and the patient was only successful in 28 cases (Canadian Medical Protective Association, 1994).

Physicians have been sued more frequently than any other health occupational group. As a result, they carry large amounts of malpractice insurance. This is changing, as other health care professionals are exercising increasing responsibility for the delivery of health care services and are more likely to be insured now.

Lawsuits may also be brought against health care professionals and health care facilities for breach of contract. A patient may commence an action for breach of contract if guaranteed a result that does not occur, or if not provided with appropriate care that was an implied part of the contractual agreement between the health care professional and patient. Given the current climate of change, it is likely that health care providers will be targeted with more lawsuits in the future.

@SUBHEADING = Breach of Fiduciary Duty

Physicians and other health care professionals are in  a fiduciary relationship (or one of the utmost good faith) with their patients, and have a legal and ethical obligation to disclose to patients all available options, including those options which might be available to the patient elsewhere. Physicians, in particular, are in a position to grant or deny access to health care procedures,and must make decisions in a manner that is in the patient’s best interests. A failure to disclose all relevant information may result in a lawsuit being commenced on the basis of a breach of fiduciary duty on the part of the health care professional.

@SUBHEADING = Administrative Remedies

Courts also have the authority to review administrative decisions under certain circumstances. Ordinarily, administrative review is available to persons who are directly affected by a decision-maker’s decision, but this remedy is open to those who are not directly affected if the public interest test is met. For example, if a Regional Health Authority decided not to offer hospital services in a region, that decision might be challenged in the courts. Administrative decisions may be challenged on the basis of lack of jurisdiction, lack of regulatory authority, or breach of the rules of natural justice.

@MINORHEADING = Conclusion

@BODY TEXT - NVJ = It is debatable whether Canadians have a legal right to health care. Even if this right has not been entrenched in law, if cost cutting measures reduce access to health care services, there may be legal remedies available. These remedies constitute a valuable arsenal for individuals who wish to challenge decisions that limit their access to health care services. The extent to which the courts will be prepared to accept defences based upon lack of resources or cost-containment strategies has yet to be determined. What is clear, however, is that if cost-cutting begins to be widely implemented, there will be an increasing number of resource allocation lawsuits and the resulting decisions will have a significant impact on health care reform.

@MINORHEADING = References

@REFERENCES = Canadian Bar Association Task Force. (1994). What’s law got to do with it? Health care reform in Canada. Ottawa: Author.

@REFERENCES = Canadian Charter of Rights and Freedoms, Part I of the Constitution Act, 1982, being Schedule B of the Canada Act 1982 (U.K.). (1982). c. 11.

@REFERENCES = Canadian Medical Protective Association. (1994, August). Annual report. Ottawa: Author.

@REFERENCES = Caulfield, T.A. (1994). Suing hospitals, health authorities and the government for health-care allocation decision. Health Law Review, 3(1), 7-10.

@REFERENCES = Hogg, P.W. (1985). Constitutional law of Canada (3rd ed.). Toronto: Carswell.

@REFERENCES = Jackson, M. (1988). The protection of welfare rights under the Charter. 20 Ottawa L.R. 257.

@REFERENCES = Schacter v. Canada. (1992). 2 SCR 679.

@REFERENCES = Schneider v. the Queen. (1982). 2 SCR 112.

@CHAPTERNUMBER = Chapter 7

@MAINHEADING = Health Care System Quality

@AUTHORNAME = Donald P. Schurman and Heather A. Andrews

Quality and health care! The two terms are so strongly related that the mention of one commonly evokes thoughts of the other. It is hard to imagine health care services being provided without a strong quality commitment. In fact, the Canadian health care delivery system was designed and has been operated with the intention of providing high quality care to all consumers. But what is really meant by health care quality? And who defines quality care?

This chapter provides an overview of mechanisms that attend to quality of health care, and a brief critique of the effectiveness of current quality approaches. It also introduces three dilemmas: access to services, adverse outcomes, and cost effectiveness. Public input is then urged.

@MINORHEADING = The Provision of Quality

The processes for providing health care services are complex. Most services are delivered by highly trained, expert staff in institutions. Patients are often quite vulnerable, as they tend to be sick and in unfamiliar surroundings. Health care professionals, having recognized this vulnerability, assume much of the responsibility for ensuring quality care. Organizational structures, regulations, and procedures have also been designed with the intent to ensure quality care. There are many aspects of quality, but five are particularly important.

@SUBHEADING = Medical Staff

The medical profession operates with the belief that quality of medical care is best ensured by having high quality training programs, licensing of qualified practitioners, and ongoing requirements and expectations of those practitioners. Through such processes, it hopes to ensure that only competent, ethical physicians are entitled to practice medicine. The following are examples: (a) each province has a College of Physicians and Surgeons that oversees the practice of physicians, investigating professional competence and complaints of misconduct against licensed practitioners, (b) the Medical Council of Canada examines candidates on behalf of the various provincial licensing organizations, (c) the College of Family Physicians of Canada certifies physicians who complete a two-year residency program in family practice, and are approved by the College and pass its examination, and (d) the Royal College of Physicians and Surgeons oversees specialty training in Canada by approving residency training programs in specialty areas, and administers the written, oral, and clinical examinations for all those seeking certification as a specialist.

@SUBHEADING = Registered Nurses

Today’s nurses, for the most part, receive their initial education in community colleges or universities. The title Registered Nurse (RN) cannot be used unless the nurse has passed a national entrance examination and is currently registered by the relevant provincial nurses’ association or college. The purpose of registration is to ensure that nurses initially possess a standard of education and knowledge, and then continue to practice proficiently. Nurses must apply annually for registration, and must meet all practice and other requirements before being re-registered. Nursing associations investigate all complaints against nurses, and act according to it’s mandate of “securing the provision of safe, competent, and ethical nursing care” (AARN, 1991).

@SUBHEADING = Other Health Care Professions

Other professions are similarly organized and regulated to protect the public from incompetent or unethical practice. One basis for this is professional legislation. Alberta, for example, has legislation regulating 29 health occupations. Through these Acts, professions are self-governing, and establish their own minimum standards of education and practice.

Many para-professionals, generally those not possessing a university education, also contribute to delivery of health care. These persons do not have professional bodies governing their practice. Instead, they are usually governed by the organization in which they work. Professionals and para-professionals alike work in a system where quality measures have been built in.

@SUBHEADING = Canadian Council on Health Services Accreditation

Accreditation is a major quality measure. The Canadian Council on Health Services Accreditation was incorporated in 1958 to set standards for Canadian hospitals and to evaluate compliance with them. The original sponsoring organizations included the Canadian Hospital Association, the Canadian Medical Association, the Royal College of Physicians and Surgeons, and the Canadian Nurses Association. These sponsors, together with recent additions from the Canadian Long Term Care Association, the Canadian College of Health Service Executives, and the Association of Canadian Teaching Hospitals, are now represented on the governing Board of Directors.

The Council aims to promote and improve the delivery of health care services in hospitals and long-term care facilities through voluntary compliance with standards established by the Council’s Board. Upon an organization’s request, the Council will send a team of surveyors to visit the health organization and, upon receiving the recommendations of the surveyors, the Board will determine whether the organization will be granted one of a number of accreditation awardsΧthe highest being a four-year award. A 3 or 4 year award indicates a very progressive, safe, and modern facility. Organizations have also been denied accreditation, or have had a number of problem areas identified which eliminated their immediate possibility of getting a 3 or 4 year award. In Alberta, only approximately 50% of acute care hospitals and 25% of long-term care facilities are accredited. Most large institutions are.

@SUBHEADING = Provincial Health Care Regulations

In addition to the above, all provincial governments enact policies and regulations intended to control the operation of the health care system and thereby protect the public from harm. For example, governments generally take the responsibility for determining the number and location of health care facilities. Governments also determine the health programs that will be offered and the level of funding to support these programs. Provincial health regulations require that health care providers meet certain standards, including volume of service, competence of staff, building codes, and safety protocols. Governments generally retain the right to seize any facility they assess is being managed in an unsafe manner. In addition, some provinces provide boards or individuals (ombudsmen) to investigate concerns and complaints.

@MINORHEADING = Effectiveness of Current Approach

There is no question that much is being done in the area of quality. Every organization and profession has developed a complex system of measures and processes to improve the quality of care. Risk management, quality assurance, and quality improvement programs have been set up in most health care organizations to prevent accidents, minimize risks, and provide effective customer service. An analysis of all of this activity, however, reveals a fragmented and incomplete approach to quality.

Part of this concern may be due to a lack of a universally accepted definition of “quality care”. It stands to reason that if “quality care” has no single definition, there can be no single way to measure and improve quality. This lack of precision, together with a highly professionalized service where self-governance is the overriding quality concept, will certainly lead to fragmentation. Each profession is likely to define quality from it’s own perspective and in a way that serves it’s needs as a professional group. This can be at the expense of quality of the overall process. For example, think of a situation where a specialist performs surgery but then, because the system is not designed otherwise, has no knowledge of the patient’s care upon discharge from hospital. Without proper education and follow-up after discharge by a rehabilitation team, the patient might suffer complications. The surgeon may be extraordinarily gifted but the end result of care is unacceptable. Fragmentation of care exists far more than we would like to admit.

Who then should be responsible for the overall quality of health care? Who is in charge? Indeed the overall responsibility for quality seems always to be someone else’s responsibility. The lack of a common definition for quality, together with no one accepting responsibility and accountability, has led to some quality issues. But before examining a few of the issues, a definition of quality is required to create a framework for this analysis.

@MINORHEADING = A Definition of Quality

Rachlis and Kushner (1994), in their book Strong Medicine, present two definitions of quality. A definition focusing on clinical decision making and cost reads as follows: “A service is considered appropriate when the best scientific evidence indicates in advance that it would be of some net benefit to the patient and when the service costs no more than an equally effective alternative” (p. 96). They also present another more popular definition which describes quality as “the right service, at the right time, delivered by the right person, in the right place” (p. 96).

While the second definition is commonly used, it does not fully define qualityΧparticularly from the perspective of the patient. The assessments of “right” remain exclusively with the health professionals. Patients however should be the best judges of whether they received quality care or not. It is not easy though to be a knowledgeable consumer, one that can accurately judge quality of care.

It is for this reason that a definition presented by Laffel (1992) has some appeal. Laffel defines quality as “meeting the needs and expectations of patients and/or other customers with a minimum of effort, rework, and waste.” Quality in health care has a number of dimensions and Laffel’s definition starts to get close to all of them. First, it is about providing services that the patient both needs and wants. Second, it is about providing services with extraordinary competence, and in a way that patients find satisfying. Third, given the fiscal demands on our system, there must be concern about the efficiency of health care deliveryΧabout minimizing effort, rework, and waste.

@MINORHEADING = Current System Performance Indicators

More and more effort is being directed towards measuring the performance of our health care system. While there are many positive results, this chapter concentrates on some areas of concern. It is important to recognize deficiencies as a way to improve overall performance of the system. According to Laffel’s definition of quality, the public is or should be interested in: (1) access to services, (2) competent performance and satisfactory outcomes, and (3) as taxpayers, minimum waste of resources.

@SUBHEADING = Access to Services

All Canadian citizens are currently entitled to care when indicated. By and large, waiting lists for services are acceptable. But do all of these services need to be provided? Research is finding cause for concern. For example, Naylor, Anderson and Goel (1994) reported that the hip replacement rate varied from 49.9 surgeries per 100,000 people in the borough of East York (Toronto) to a high of 112.5 per 100,000 in the region of HuronΧa difference of over 100%. Another interesting finding was a great difference in coronary artery bypass surgery rates: from 164.6 per 100,000 population in the Sudbury area to a low of 6.7 in the Kenora regionΧa huge difference that was unexplainable. Similar variations in other surgery rates across Ontario were also cited.

This variation has been found to exist across Canada (MacBride-King, 1993). Hospital Medical Records Institute data for the years 1990-1991, for example, report the rate of gall bladder surgery varied from 476 per 100,000 women in Newfoundland to a much lower rate of 298 in British Columbia. These patterns of variation are leading many to suggest that a number of interventions are questionable and perhaps even unnecessary. Larkin, a former Ontario health minister, claimed that as much as one-third of all medical care delivered in Canada was unnecessary (Rachlis & Kushner, 1994). Wennberg, a professor of epidemiology at the Dartmouth Medical School, suggested that as many as half of all elective surgical procedures may be inappropriate because patient preferences are not taken into account (Rachlis & Kushner, 1994).

Variation may be due to the fact that we cannot predict who will or will not benefit from a specific intervention. This circumstance forces physicians into making decisions about treatment based on their own past experiences. Wennberg, who was concerned about this lack of science for decision-making, pioneered a system of shared decision-making (Rachlis & Kushner, 1994). Patients were provided with complete information on the potential benefits and risks of undertaking certain procedures and the comparative benefits and risks of conservative treatments. Wennberg’s study found patients to be more risk adverse than physicians, as they frequently opted for “simply waiting.” Shared decision-making tended to decrease utilization.

@SUBHEADING = Performance and Outcomes

The Canadian health care system has an outstanding reputation for providing quality services. But is this reputation warranted? A Harvard study (reported by Rachlis & Kushner, 1994), examined the records of 30,000 patients admitted to a New York hospital. In one year, the investigators found that nearly 7,000 patients died and an additional 1,700 were permanently disabled because of negligent hospital care.” Weiler, a Canadian, believes the results would not be much different in Canada (Rachlis & Kushner, 1994). Care of this quality is not acceptable. Outcome measures have now become a major focus of interest in the health care system, with an aim to minimize futile or harmful care.

@SUBHEADING = Cost Effectiveness

Quality must also consider waste and costsΧa particularly important issue now. As Angus, Auer, Cloutier and Alberta (1995) described, over the past three decades, health care expenditures in Canada have consistently grown faster (an average of 12% per year) than the overall economy (an average of 10% per year). Alberta, for example, has seen remarkable growth in health expenditures over the period from 1980-81 to 1992-93. Over that period of time health expenditures rose by 160% while economy-wide inflation was approximately 83% and population growth was only 10.8% (Alberta Health, 1993, p. 7,8). Clearly, this trend is not sustainableΧeven in provinces considered by some to be wealthy.

These figures may not be so difficult to accept if the health status of the population increased in line with increased expenditure. This has not happened. Most of the increased costs are due to a growth in utilization of hospitals, of technologies, and of drugsΧsome of which are of questionable appropriateness. A second major factor for cost increases is inherent in the health care system itself. Many of the processes associated with the delivery of care and services have become unnecessarily cumbersome, complex and inefficient. Streamlining the system is fraught with challenges. For example, attempts to reassign work to the least expensive, but appropriately trained group, is often met with opposition by unions and rival professional groups. Third, the health care system has created incentives that promote volume rather than conservative use. For example, physicians are usually reimbursed according to the number of procedures they performed. Hospitals are also commonly funded by the number of patient days used. Both are rewarded on the basis of doing more, not doing less. Finally, the governance and management structures of health care organizations have produced barriers to appropriate resource deployment. Individual institutions have tended to be competitive rather than collaborative in providing programs to communitiesΧthe result is unnecessary duplication of programs. In summary, many complex factors contribute to inefficient and ineffective use of resources. All such issues in health could be addressed through a strong commitment to quality management.

@MINORHEADING = The Future

Despite current barriers, the future regarding quality in Canadian health care is optimistic. The health care system is responding, in many ways, to the problems and issues identified earlier. In particular:

@BULLET = health care organizations are already beginning to define quality from the consumer’s point of view.

@BULLET = new quality improvement tools are being used to understand and improve work processes. Quality improvement relies on full staff involvement, resulting in a growing awareness among health team members of the need to improve and a growing capability for making necessary changes.

@BULLET = research is identifying those interventions that work and those that do not. A great improvement in quality could occur if existing resources were applied in a more focused way to interventions that provide a clear benefit to the patient.

@BULLET = new organizational arrangements are forming effective linkages among health care organizations in the same community. Regional authorities in Alberta, and other provinces, are now responsible for the provision of all health care services in a region. Regional boards can rearrange the delivery system and provide services in only their highest performing organizations if they so choose. And they can more easily close programs of substandard quality.

Much more needs to be done, however, if our system hopes to maintain its standing as one of the finest systems in the world. The future will be more promising if the public takes a direct interest in health care, and becomes more informed and demanding.

@MINORHEADING = The Public Role

Patients have tended to be passive consumers of health care. Decisions have commonly been made for individual patients and for the public as well. We believe a new balance of authority and responsibility in decision-making needs to emerge. Three initiatives are of primary importance in creating this new balance: (1) consumer input to providers, (2) consumer involvement in decision making, and (3) provider accountability for the assessment of outcomes.

@SUBHEADING = Consumer Input to Providers

It is naive and inappropriate to believe that the members of the health care community know best what services should be provided to the public or to individual patients. An informed public knows what it needs and expects from the system. What is needed is a mechanism where public interests and needs are regularly and effectively surveyed. Health care organizations could then be assessed as to how well they are performing against public expectations, and make adjustments when expectations are not met.

@SUBHEADING = Consumer Involvement

@BODY TEXT - NVJ = Health care customers must also assume more responsibility. It is no longer acceptable to undertake treatment without full awareness of potential risks and benefits. If this change demands more research on the outcomes of interventions; then hospitals, physicians, and other providers must develop and share this information. In many cases, though, there must be greater efforts to inform patients about their treatment and to give them control over decisions. Governments must also design mechanisms for obtaining public input for the ongoing delivery of health care.

@SUBHEADING = Provider Accountability

@BODY TEXT - NVJ = Provincial health departments and their delegates remain ultimately responsible for access to and quality of the health care system. Provincial health departments and regional authorities must be urged by the public to demand outcome measures for all funded programs. These measures should report on more than just cost. Timely access to care, the quality of delivery in terms of outcomes, and the ultimate value and health impact of the service as measured by the patient are all extremely important.

@MINORHEADING = Concluding Remarks

@BODY TEXT - NVJ = The Canadian health care system is the envy of people around the world. Most would say it is a high quality system. Yet, the system that has succeeded in providing accessibility at reasonable cost has three quality problems that require attention and resolution: some interventions may be questionable or unnecessary, some interventions do not enhance health status in the longer term, and costs are rising to unacceptable levels.

@BODY TEXT - NVJ = Although the health care system does have agencies in place to monitor and improve the quality of health services delivery, more effective involvement of the public through customer input to providers, consumer involvement in decision making and enhanced requirements for outcome measurement is now necessary. Through enhancement of mechanisms to attend to health care system quality, Canada’s jewel (its health care system) can be preserved and enhanced to even greater levels of quality in helping meet the needs of its citizens.

@MINORHEADING = References

@REFERENCES = Alberta Association of Registered Nurses. (1991). Mission statement. Edmonton, AB: Author.

@REFERENCES = Alberta Health. (1993). Our bill of health: A roundtable on health 1993. Edmonton: Author.

@REFERENCES = Angus, D.E., Auer, L., Cloutier, J.E., & Alberta, T. (1995). Sustainable health care for Canada: Synthesis report. Ottawa: University of Ottawa.

@REFERENCES = Laffel, G. (1992, June 4). Paper presented at the University of Alberta Hospital Board and Medical Staff Retreat. Kananaskis, Alberta.

@REFERENCES = MacBride-King, J. (1993, Summer). “Prescription for change: An interview on improving Canada’s health care system with Donald P. Schurman, President, University of Alberta Hospitals.” Canadian Business Review, 20(2), 6-14.

@REFERENCES = Naylor, C.D., Anderson, G. M. & Goel, V. (Eds.). (1994). Patterns of health care in Ontario (report produced by the Institute for Clinical Evaluative Sciences). Ottawa: Canadian Medical Association.

@REFERENCES = Rachlis, M. & Kushner, C. (1994). Strong medicine. Toronto: Harper Collins.

@CHAPTERNUMBER = Chapter 8

T he Canadian Health Care System:

@MAINHEADING = Trends, Issues, And Challenges

@AUTHORNAME = Doris Kieser and Donna M. Wilson

In this final chapter, major trends, issues and challenges for the Canadian health care system are highlighted. Some of these have been discussed in preceding chapters, so they will only be minimally outlined here. The Oxford Dictionary defines a trend as a “general direction or tendency”, an issue as a “point in question” or an “important topic for discussion”, and a challenge as a “calling to respond”, particularly to a “demanding or difficult task”. Trends, issues and challenges are not necessarily bad or good, but with regard to health care in Canada, they are far from being resolved. As a consequence, the future appearance of our health care system is uncertain now and may be for some time.

@MINORHEADING = Change

One of the most obvious trends in health care today is major change (Canadian Hospital Association, 1993). As a result, the health care system of tomorrow will be significantly different from what it is today. Changes are currently taking place in most, if not all, health care organizations and sectors of the health care system (Angus & Turbayne, 1995). In particular, health care organizations across Canada are downsizing, and are changing what they do and how they do it. Most provinces are using regionalization to initiate and make change, aiming for better coordination and cost of health care delivery efforts within specific geographic or health regions. Whether we rely on the health care system for health care or for employment, all of us will be affected in some way by these changes.

One reason for this is that any one change will lead to further changes. For example, the decision to downsize, or close one half of all acute care hospital beds in Alberta, has moved much of the care previously done in hospitals to the home (Alberta Health, 1995). Alberta had a relatively high number of inpatient beds in comparison to a national average (Jacobs, 1993). Yet, bed closures, particularly because they occurred rapidly over a two year period, are having a major effect on patients and their families (especially women, who provide most home care). Many hospital staff have been made redundant, while at the same time the workload and complexity of work increased for home care agencies (Alberta Health, 1995). Alberta is not the only province to deinstitutionalize parts of health care. Most provinces are doing this in the areas of mental health, long-term care, and acute hospital care.

Patients, their families, health care providers, and communities across Canada have been challenged in many ways by bed reductions. With regard to this change, however, there is a major issue which has yet to be resolved: Who will provide and pay for the direct and indirect costs of health care in the home? For example, if daily care is necessary in the home, will a home care worker or a family member provide it? Who will pay for the home care worker’s salary or the loss in wages and career opportunities for that family member? In addition, who will purchase the necessary supplies and bring them home?

Another issue is public confidence in our Medicare system as it undergoes change. Change is not easy, particularly since we have enjoyed a relatively stable 30 years of Medicare, during which time this system grew to be what it is today. Most Canadians are accustomed to having hospitals and other forms of health care readily available. As hospitals close or other changes are made, people now question whether they will be able to get health care when necessary. The challenge now and for the future is to make beneficial changes while keeping the public’s confidence. Ongoing careful planning, real public participation in planning, and repeated communication of changes will be required to maintain public confidence.

@MINORHEADING = Business Orientation

Changes that cause improvements should be expected in any system, particularly in our quality-oriented health care system. But, why is change so prevalent now? One of the most important reasons is that fiscal imperatives or economic indicators are driving change. This does not necessarily mean that our health care system costs too much, or that Canada cannot afford a publicly-funded health care system (Evans, 1992). Rather, it means that deficits and accumulating debt have caused governments to take action. Economic forces such as these have facilitated a business orientation in health care. This orientation focuses more on costs and cost-benefits of health care, and less on the elimination of suffering and support of life and limb. Many issues and challenges have resulted from this new orientation.

Two of the most important issues that result from a “bottom line”, corporate or business approach to health care involve maintaining quality and equity. No one would disagree that the health care system must be affordable and sustainable. But does this mean that health care should stop being available to all people? Does this also mean that the quality of the health care system needs to suffer? A low quality public system or a system that does not serve all people will quickly devolve into a tiered system, with private businesses providing what was once a public responsibility. Moving toward a system for the rich and a system for the poor would be a regrettable step. Yet, it is an “easy solution” (Angus & Turbayne, 1995, p. 96) and one advocated by the entrepreneurs who would benefit much from a profit orientation in health care. The challenge now is whether or not changes will ensure the continuation of a quality publicly-funded health care system.

@MINORHEADING = Addressing Costs

Since 1977, the federal government has been reducing the amount of money it transfers to provinces for health care (Taylor, 1981), while the provinces continue to be responsible for its delivery. Provinces are in the increasingly difficult position of having to contain health care costs or shift costs elsewhere. Shifting costs means that some source other than government pays for health care (either individuals, private health care insurance companies, or employers).

Reducing the total number of hospital beds is an example of cost shifting and cost containment. Having more patients at home, what is now known as the “hospital-without-walls” concept (Wetherill, 1992), reduces the cost associated with 24 hour care in institutions. A cost shift also occurs if patients or their families pay for health care supplies and professional caregiving in the home, resources previously provided at public expense in hospital. By making this change, provinces could reduce hospital expenditure. However, if home care is not well planned and patients are readmitted to hospitals with complications, then provinces may not achieve any long-term savings. Re-admissions generally involve a long hospital stay, with more extensive and expensive care necessary than originally needed. Home care can be as comfortable and perhaps even more appropriate than institutional care. The challenge then is to redesign hospital and home care systems to support a successful shift of care to the home.

Another example of a cost shift is facility fees. In 1984, the Canada Health Act was specifically designed to prevent user fees. Having people pay part of their hospital or medical bill, either through a direct payment or through private insurance, shifts part of the cost of the health care system from governments to individual citizens. Some people believe that this shift will help control costs by reducing abuse of the system, as people are expected to be less likely to use health care if they have to pay directly for it. Since there is very little deliberate abuse of our public health care system, the issue of equal access to health care arises. A user fee or facility fee will not deter wealthy people from receiving necessary health care, however poor people are certainly deterred (a Canadian example of this is Beck & Horne’s 1980 Saskatchewan study). In fact, this form of cost shift would have a “devastating impact on the health of poor people” (Rachlis & Kushner, 1994, p. 154). Since cost shifting is problematic for this and other reasons, the challenge now is for provinces to control or reduce health care costs without compromising equal access to health care. For this reason, the outcome of the federal government’s 1995 stance on penalizing provinces that allow facility fees to be charged for medically-necessary health care services, will be of major significance.

Another issue related to control of costs and quality, is whether or not the health care provided by our health care system is appropriate. There is a significant trend now toward the use of outcomes analysis or evidence-based decision-making. This new decision-making method holds much promise for a publicly-funded health care system because it aims to ensure that only appropriate care is delivered at public expense. Outcomes analysis could establish that some surgeries, medications, or treatments are unnecessary, or that less expensive alternatives are just as effective (Mackenzie et al., 1992). Outcomes analysis could also prevent the wholesale introduction of new and unproven technologies or medications. More careful adoption of new treatments, tests, and medications would also help to control health care costs.

There are, however, two major challenges for outcomes analysis. The first challenge is determining what an acceptable outcome is. Should treatments have a better than 50% chance of success before they are used? Should some treatments be required to have a higher chance of success than others? What is success? Is it necessary to have full recovery, or is partial recovery enough? Must a treatment save lives or is it valid if it merely improves quality of life? Should the cost of the therapy have an impact on the outcome analysis decision? When these questions are considered seriously, it becomes apparent that it may be difficult to reach agreement about what an acceptable outcome is. Because different things are important and valuable to different people, different outcomes may also be acceptable. For example, some people may want to live regardless of any disability, while others would find living with a disability unacceptable.

The second challenge for outcomes analysis is determining who should be involved in this process, how their involvement can be ensured, and who in the end will make the decisions. In the past, health care decisions have generally been made by experts, such as physicians on behalf of patients or health departments in the name of the common good. The rising educational level of Canadians and their increased ability to access information have made it much more possible and desirable to share decision-making. Yet despite widespread interest in greater public participation there are practical problems in actually carrying it out. For example, participatory decision-making takes more time. Most members of the public could not become involved in long debates about how to spend every health care dollar. If, however, government representatives and health care planners ignore increasing public interest in health care decision-making, then the needs of the public will not be met and public confidence in the health care system will invariably weaken.

While it is nice to think that decision-making will be shared, there are two additional questions that must be asked. First, how do we deal with the “squeaky wheel” (Friedell, 1991) and ensure an equitable or fair sharing of health care dollars? The most powerful or best organized lobby groups are better equipped to advance their cause. Other groups may suffer through their gain. Second, who is best able to weigh all the facts, and all the social implications of decisions? For example, who could appropriately weigh the cost of one heart transplant against immunizing an entire town’s population against a disease? This would be a difficult decision for anyone, and it serves to point out that although outcomes analysis holds much promise for controlling costs in a public health care system, it still faces many challenges.

An alternative to outcomes analysis is rationing. With health care rationing, fewer people receive treatment. A common form of rationing is limiting the overall availability of select treatments or services. This raises the issue of waiting times. Longer waiting times can contribute to secondary illnesses or conditions that also require treatment. Health care costs may rise as a result. The challenge then is to effectively monitor and responsibly control use of public health care funds, while not limiting access to essential health care.

Another possible form of rationing is to prohibit some people from receiving treatment. This raises the issue of who would or would not receive care. It is not ethically acceptable to withhold and withdraw treatment simply because of a person’s age or other criterion. Yet, some would use this simple solution for cutting health care costs, as opposed to a more time-consuming outcomes analysis. A major challenge for our health care system will be to maintain equality of right to health care.

@MINORHEADING = Awareness of Limitations

For some time now, there has been an awareness of the futility of some health care. In 1984 the Joint Statement on Terminal Illness was developed by Canadian nurses, doctors, lawyers, and other groups. These groups recognized then that treatment will be unsuccessful at times. Furthermore, providing useless treatment causes suffering for the patient and all involved. Since 1984 there has been a growing public awareness of futile and marginally-helpful care. Often the emotional, financial, and social costs of such care far outweigh the benefits a person may receive. The quantity-versus-quality-of-life debate will no doubt go on for many years, but it is likely that it will become clearer what is and what is not futile.

Whatever the result of that debate, we are now beginning to accept that our health care system has limitations. One limitation is that not every disease or illness can be successfully treated. There are many chronic or incurable health conditions for which the health care system can do very little. In fact, chronic illnesses, such as progressively worsening heart and lung diseases, have been the most common cause of death since the mid-1950s (Statistics Canada, 1991). Another limitation of our health care system is that it cannot afford to aggressively treat every disease, illness, or health condition. A third limitation is that not all relevant health services or treatments are publicly funded. The current health care system is limited to traditional medical and scientific-based care, and only rarely incorporates non-traditional or home based options for health care. A final limitation of our system is its primary emphasis on diagnosing and treating illnesses, as opposed to preventing them. Funds spent on diagnosing and treating illnesses are not available for other social programs, programs which do more to maintain health (Mhatre & Deber, 1992). For example, the 1994 report of the Canadian Institute of Child Health identifies the growing problem of child poverty in Canada. Almost one quarter of all children in Canada now live in poverty. Poverty is a major impediment to health, yet poverty is not addressed by our health care system. These limitations are real, and are important factors supporting change. The challenge of addressing these limitations, however, is to ensure that we do not erode the Canadian health care system.

@MINORHEADING = Conclusion

For 30 years the Canadian health care system has provided health care for all Canadians. This system has been very successful in contributing to a healthy public and also in helping make Canada what it is today. In 1981, Taylor wrote that it was “obvious that the creation of the Canadian health insurance system is viewed by most Canadians as the outstanding social, political, and economic triumph of our history” (p. 177). Then, in 1984, the Canada Health Act was developed, in the face of economic pressures, to ensure that all Canadians would continue to have equal access to essential health care. Today, economic pressures are again impacting the system, with changes being made to make the system more affordable. During this time of change, however, the health care system faces many challenges. Possibly the most serious challenge is from those who support paying privately for necessary health care. Health care is a large social, political, and economic institution, and there are many other pressures and forces to which we need to pay attention. If there is a will, however, to keep equality as the foundation for our Canadian health care system, then there will be a way to control these forces and shape our future health care system through effective change.

@MINORHEADING = References

@REFERENCES = Alberta Health. (1995). A three-year business plan, 1995-96 to 1997-98. Edmonton: Author.

@REFERENCES = Angus, D.E., & Turbayne, E. (1995, April). Path to the future. A synopsis of health and health care issues. Ottawa: National Nursing Competency Project.

@REFERENCES = Beck, R.G., & Horne, J.M. (1980). Utilization of publicly insured health services in Saskatchewan before, during, and after co-payment. Medical Care, 18(8), 27-41.

@REFERENCES = Canadian Hospital Association. (1993). National health policy reform project. An open future: A shared vision. Ottawa: Author.

@REFERENCES = Canadian Institute of Child Health. (1994). The health of Canada’s children. A CICH profile (2nd edition). Ottawa: Author.

@REFERENCES = Evans, R.G. (1992). Canada: the real issues. Journal of Health Politics, Policy and Law, 17(4),739-762.

@REFERENCES = Friedell, G.H. (1991). The >squeaky wheel’ and health care policy. Journal of the American Medical Association, 265(24), 3300.

@REFERENCES = Jacobs, P. (1993, August). Provincial hospital ambulatory services: How do Albertans use their hospitals? Health Economics Research Centre Newsletter, 2, 1-2.

@REFERENCES = Joint Statement on Terminal Illness. (1984). A protocol for health professionals regarding resuscitation intervention for the terminally ill. The Canadian Nurse Journal, 80(6), 24.

@REFERENCES = Mackenzie, T.A., Reynolds, D., Greenaway-Coates, A. (1992). Hospital reimbursement in Alberta: Outcomes management is on the way. Healthcare Management FORUM, 5(4), 21-27.

@REFERENCES = Mhatre, S.L., & Deber, R.B. (1992). From equal access to health care to equitable access to health. A review of Canadian provincial and health commissions & reports. International Journal of Health Services, 22(4), 645-668.

@REFERENCES = Rachlis, M., & Kushner, C. (1994). Strong medicine. How to save Canada’s health care system. Toronto: Harper Collins.

@REFERENCES = Statistics Canada. (1991). Canada yearbook 1992. Ottawa: Author.

@REFERENCES = Taylor, M.C. (1981, June). Health care system. Journal of Public Health Policy, 177-187.

@REFERENCES = Weatherill, J. (1992). Beyond four walls: Ideas and applications on regional planning of health care services. Healthcare Management FORUM, 5(4), 48-53.

@MAINHEADING = Conclusion

Eight chapters have described distinct, but overlapping, parts of the Canadian health care system. A fundamental point made repeatedly about this system is that it is primarily a public one, using pooled tax dollars to fund it. As such, the Canadian health care system is one of the most popular programs of all time. Many surveys have established the health care system to be of central importance, for a variety reasons, to Canada and to individual Canadians. This system has helped to make and identify Canada as a nation. The Canadian health care system in particular is distinctly different from our neighbour’s to the south, and many Canadians take great pride in this fact. The Canadian system, while controlling costs much better than in the USA, promises quality health services to all Canadians.

The benefit of having good health care available without financial access barriers did not come about by chance. It has taken leadership, political will, and Canadian resolve to form such a system and keep it. In 1994 and 1995, through a Canada-wide study that a research team (of which I was a member) undertook, we found 98% of the participants fully supported the intent of the Canada Health Act - that being to ensure access to health care for every Canadian. Previous surveys have found approximately 85% of Canadians support our publicly-funded health care system. Perhaps now, in a time of threat, people treasure something they could lose.

Our research study also found most participants believed our health care system could or must change. This is not surprising, as any large system should keep pace with the times. But what was even more important, was their belief that the health care system could be made more cost-effective, while at the same time not lose the intent of the Canada Health Act. Changes, according to them, should not reduce the universal, portable, or accessible nature of our Medicare system. This pointed out to us the need for Canadians to resist anything but positive changes. Positive changes would preserve a health care system for ALL Canadians.

Since the Canadian health care system was developed by Canadians, and is used and supported by Canadians, it is only right that Canadians be consulted and be involved in health care system changes (see Appendix B: Consumer Rights to Health Care). Some proposed changes today threaten universality, accessibility, comprehensiveness, portability, and public administration - the principles of our health care system.

I hope this book helps Canadians to not only be informed, but also to be involved in preserving a health care system that is fundamental to the well-being of our nation.

Donna M. Wilson

Editor

The editor would like to acknowledge the excellent work of the authors and reviewers.

@MAINHEADING = Appendix A

@MINORHEADING = Principles of the 1984 Canada Health Act (Excerpts)

Note: The exact wording of relevant sections of the Canada Health Act is used below.

In order that a province may qualify for a full cash contribution...for a fiscal year, the health care insurance plan of the province must, throughout the fiscal year, satisfy the criteria:

@BULLET A,B,C = public administration;

@BULLET A,B,C = comprehensiveness;

@BULLET A,B,C = universality;

@BULLET A,B,C = portability; and

@BULLET A,B,C = accessibility. 1984, c. 6, s. 7.

@SUBHEADING = Public Administration.

In order to satisfy the criterion respecting public administration,

@BULLET A,B,C = the health care insurance plan of a province must be administered and operated on a non-profit basis by a public authority appointed or designated by the government of the province;

@BULLET A,B,C = the public authority must be responsible to the provincial government for that administration and operation; and

@BULLET A,B,C = the public authority must be subject to audit of its accounts and financial transactions by such authority as is charged by law with the audit of the accounts of the province.

@SUBHEADING = Comprehensiveness.

In order to satisfy the criterion respecting comprehensiveness, the health care insurance plan of a province must insure all insured health services provided by hospitals, medical practitioners or dentists, and where the law of the province so permits, similar or additional services rendered by other health care practitioners.

@SUBHEADING = Universality.

In order to satisfy the criterion respecting universality, the health care insurance plan of a province must entitle one hundred per cent of the insured persons of the province to the insured health services provided for by the plan on uniform terms and conditions.

@SUBHEADING = Portability.

In order to satisfy the criterion respecting portability, the health care insurance plan of a province

@BULLET A,B,C = must not impose any minimum period of residence in the province, or waiting period, in excess of three months before residents of the province are eligible for or entitled to insured health services;

@BULLET A,B,C = must provide for and be administered and operated so as to provide for the payment of amounts for the cost of insured health services provided to insured persons while temporarily absent from the province on the basis that

@BULLET I,II,III = where the insured health services are provided in Canada, payment for health services is at the rate that is approved by the health care insurance plan of the province in which the services are provided, unless the provinces concerned agree to apportion the cost between them in a different manner, or

@BULLET I,II,III = where the insured health services are provided out of Canada, payment is made on the basis of the amount that would have been paid by the province for similar services rendered in the province, with due regard, in the case of hospital services, to the size of the hospital, standards of service and other relevant factors; and

@BULLET A,B,C = must provide for and be administered and operated so as to provide for the payment, during any minimum period of residence, or any waiting period, imposed by the health care insurance plan of another province, of the cost of insured health services provided to persons who have ceased to be insured persons by reason of having become residents of that other province, on the same basis as though they had not ceased to be residents of the province.

@SUBHEADING = Accessibility.

In order to satisfy the criterion respecting accessibility, the health care insurance plan of a province

@BULLET A,B,C = must provide for insured health services on uniform terms and conditions and on a basis that does not impede or preclude, either directly or indirectly whether by charges made to insured persons or otherwise, reasonable access to those services by insured persons;

@BULLET A,B,C = must provide for payment for insured health services in accordance with a tariff or system of payment authorised by the law of the province;

@BULLET A,B,C = must provide for reasonable compensation for all insured health services rendered by medical practitioners or dentists; and

@BULLET A,B,C = must provide for the payment of amounts to hospitals, including hospitals owned by or operated by Canada, in respect of the cost of insured health services.

@MINORHEADING = Definitions Contained in the Canada Health Act

Dentist means a person lawfully entitled to practice dentistry in the place in which the practice is carried on by that person;

Extended health care services means the following service, as more particularly defined in the regulations, provided for residents of a province, namely, (a) nursing home intermediate care service, (b) adult residential care service, (c) home care service, and (d) ambulatory health care service;

Extra-billing means the billing for an insured health service rendered to an insured person by a medical practitioner or a dentist in an amount in addition to any amount paid or to be paid for that service by the health care insurance plan of a province;

Health care insurance plan means, in relation to a province, a plan or plans established by the law of the province to provide for insured health services;

Health care practitioner means a person lawfully entitled under the law of a province to provide health services in the place in which the services are provided by that person;

Hospital includes any facility or portion thereof that provides hospital care, including acute, rehabilitative or chronic care, but does not include (a) a hospital or institution primarily for the mentally disordered, or (b) a facility or portion thereof that provides nursing home intermediate care service or adult residential care service, or comparable services for children;

Hospital services means any of the following services provided to in-patients or outpatients at a hospital, if the services are medically necessary for the purpose of maintaining health, preventing disease or diagnosing or treating an injury, illness or disability, namely, (a) accommodation and meals at the standard or public ward level and preferred accommodation if medically required, (b) nursing service, (c) laboratory, radiological and other diagnostic procedures, together with the necessary interpretations, (d) drugs, biologicals and related preparations when administered in the hospital, (e) use of operating room, case room and anaesthetic facilities, including necessary equipment and supplies, (f) medical and surgical equipment and supplies, (g) use of radiotherapy facilities, (h) use of physiotherapy facilities, and (i) services provided by persons who receive remuneration therefor from the hospital, but does not include services that are excluded by the regulations;

Insured health services means hospital services, physician services and surgical-dental services provided to insured persons, but does not include any health services that a person is entitled to and eligible for under any other Act of Parliament or under any Act of the legislature of a province that relates to workers’ or workmen’s compensation;

Insured person means, in relation to a province, a resident of the province other than (a) a member of the Canadian Forces, (b) a member of the Royal Canadian Mounted Police who is appointed to a rank therein, (c) a person serving a term of imprisonment in a penitentiary as defined in the Penitentiary Act, or (d) a resident of the province who has not completed such minimum period of residence or waiting period, not exceeding three months, as may be required by the province for eligibility for or entitlement to insured health services;

Medical practitioner means a person lawfully entitled to practice medicine in the place in which the practice is carried on by that person;

Physician services means any medically required services rendered by medical practitioners;

Resident means, in relation to a province, a person lawfully entitled to be or to remain in Canada who makes his home and is ordinarily present in the province, but does not include a tourist, a transient or a visitor to the province.

@MAINHEADING = Appendix B

@MINORHEADING = Consumer Rights to Health Care*

@SUBHEADING = 1. Right to be informed

@BULLET A,B,C = about preventative health care including education on nutrition, drug use, birth control, appropriate education

@BULLET A,B,C = about the health care system including the extent of government insurance coverage for services, supplemental insurance plans, the referral system to auxiliary health and social facilities and services in the community

@BULLET A,B,C = about the individual’s own diagnosis and specific treatment program including prescribed surgery and medication, options, effects and side effects

@BULLET A,B,C = about the specific costs of procedures, services and professional fees undertaken on behalf of the individual consumer.

@SUBHEADING = 2. Right to be respected as the individual with the major responsibility for their own health care

@BULLET A,B,C = right that confidentiality of his health records be maintained

@BULLET A,B,C = right to refuse experimentation, undue painful prolongation of life or participation in teaching programs

@BULLET A,B,C = right of adult to refuse treatment, right to die with dignity.

@SUBHEADING = 3. Right to participate in decision making affecting their health

@BULLET A,B,C = through consumer representation at each level of government in planning and evaluating the system of health services, the types and qualities of service and the conditions under which health services are delivered

@BULLET A,B,C = with the health professionals and the personnel involved in his direct health care.

@SUBHEADING = 4. Right to equal access to health care (health education, prevention, treatment and rehabilitation) regardless of the individual’s economic status, sex, age, creed, ethnic origin and location

@BULLET A,B,C = right to access to adequately qualified health personnel

@BULLET A,B,C = right to a second opinion

@BULLET A,B,C = right to prompt response in emergencies.

*Note: permission to reproduce the Consumer Rights to Health Care was obtained from Wendy Armstrong, Consumers’ Association of Canada (Alberta). These Rights were originally developed by the Consumers’ Association of Canada in 1972 and were reaffirmed in 1989.

@MAINHEADING = List of Authors

Heather A. Andrews, PhD, is a nurse with specialization in health services administration and educational administration. She is an Edmonton-based consultant in health care delivery and education. Prior to this, she was a Vice President of a large hospital.

Meluccia M. Di Marco is a graduate student at the University of Alberta. She is also employed as a Speech Language Pathologist, and works with deaf children in Edmonton.

P. L. James is a lawyer, who is the Executive Director of the Health Law Institute at the University of Alberta.

Doris M. Kieser has a Master’s degree in theology. She is an independent consultant in the areas of ethics, health reform and social policy. She resides in Edmonton, Alberta.

Herbert C. Northcott, PhD, is a Sociologist, who has studied and written extensively about the health care system. He is a Professor in the Department of Sociology at the University of Alberta in Edmonton.

Cheryl Rehill is an undergraduate nursing student at the University of Alberta. Following graduation, she would like to work in the areas of community-based mental health, women’s issues, and native health.

Donald P. Schurman is a health care executive, residing in Edmonton, who until recently was the President and CEO of one of the largest hospitals in Canada. His background includes a Master’s degree in Health Services Administration, and extensive involvement in organizations across North America which promote quality in health care.

Janet L. Storch, PhD, is a nursing professor and past Dean of the Faculty of Nursing at the University of Calgary. She specializes in bioethics and in health services administration.

Gregg Trueman is an undergraduate nursing student at the University of Alberta. He currently works in palliative home care and plans to undertake a graduate nursing program specializing in palliative care.

Corrine Truman is a registered nurse who is pursuing PhD studies in Sociology at the University of Alberta. She also works part-time as a home care nurse, and has an independent consulting business.

Donna M. Wilson, PhD, is a registered nurse with a PhD in Educational Administration, who teaches nursing at the University of Alberta. She conducts research in the areas of health care reform and end-of-life care.

Douglas R. Wilson, MD, FRCPC, until recently was the Dean of the Faculty of Medicine at the University of Alberta. He is currently working in the Department of Public Health Sciences at the University of Alberta, and is developing the interdisciplinary Centre for Health Promotion Studies.

@MAINHEADING = List of Reviewers

@BODY TEXT - NVJ = The following persons voluntarily reviewed one or more chapters of this booklet. The authors and editor are indebted to them.

@BODY TEXT - NVJ =

@BODY TEXT - NVJ = Dr. Heather A. Andrews

@BODY TEXT - NVJ = Ms. Nancy Betkowski

@BODY TEXT - NVJ = Ms. Elizabeth Bishop

Mr. Tim Caulfield

@BODY TEXT - NVJ = Dr. Ruth Collins-Nakai

@BODY TEXT - NVJ = Ms. Jean Dobbie

@BODY TEXT - NVJ = Dr. John Dossetor

@BODY TEXT - NVJ = Dr. Lillian Douglass

@BODY TEXT - NVJ = Dr. Arthur Elliott

@BODY TEXT - NVJ = Ms. Helen Lantz

@BODY TEXT - NVJ = Dr. Judith Hibberd

@BODY TEXT - NVJ = Ms. Noela Inions

@BODY TEXT - NVJ = Ms. Kaysi Kushner

@BODY TEXT - NVJ = Ms. Mary Marshall

@BODY TEXT - NVJ = Ms. Wendy Neander

@BODY TEXT - NVJ = Ms. Debbie Phillipchuk

@BODY TEXT - NVJ = Dr. Janet Ross Kerr

@BODY TEXT - NVJ = Dr. Martin Serediak

@BODY TEXT - NVJ = Dr. Lynn Skillen

@BODY TEXT - NVJ = Ms. Corrine Truman

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