PADMASHREE SCHOOL OF PUBLIC HEALTH

HEALTH SYSTEM

-BYDr. RAHUL SHRIVASTAVA

BDS, FAGE, MPH

INTRODUCTION Canada is a North American country consisting of ten provinces

and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west and northward into the Arctic Ocean. It is the world's second largest country by total area. Canada's common border with the United States to the south and northwest is the longest in the world.

The ten provinces are 1. Alberta 2. British Columbia3. Manitoba4. New Brunswick5. Newfoundland and

Labrador 6. Nova Scotia 7. Ontario8. Prince Edward Island9. Quebec Saskatchewan

The three territories are10.Northwest Territories11.Nunavut12.Yukon

PUBLIC HEALTH SYSTEM

Health insurance plans that provides coverage to all Canadian citizens. It is publicly funded and administered on a provincial or territorial basis, within guidelines set by the federal government.

Under the health care system, individual citizens are provided preventative care and medical treatments from primary care physicians as well as access to hospitals, dental surgery and additional medical services.

Canada's health care system is the subject of much political controversy and debate in the country. Some question the efficiencies of the current system to deliver treatments in a timely fashion, and advocate adopting a private system similar to the United States. Conversely, there are worries that privatization would lead to inequalities in the health system with only the wealthy being able to afford certain treatments.

Regardless of the political debate, Canada does boast one of the highest life expectancies (about 80 years) and lowest infant morality rates of industrialized countries, which many attribute to Canada's health care system.

ORGANIZATION AND GOVERNANCE Canada has a predominantly publicly financed health system

with approximately 70% of health expenditures financed through the general tax revenues of the federal, provincial and territorial governments.

The governance, organization and delivery of health services is highly decentralized for at least three reasons:

Provincial and territorial responsibility for the funding and delivery of most health care services;

The status of physicians as independent contractors; and The existence of multiple organizations, from regional health

authorities (RHAs) to privately governed hospitals, that operate at arm’s length from provincial governments.

CANADA HEALTH ACT The Canada Health Act is federal legislation that puts in place

conditions by which individual provinces and territories in Canada may receive funding for health care services.

There are five main principles in the Canada Health Act:1. Public Administration: All administration of provincial health

insurance must be carried out by a public authority on a non-profit basis. They also must be accountable to the province or territory, and their records and accounts are subject to audits.

2. Comprehensiveness: All necessary health services, including hospitals, physicians and surgical dentists, must be insured.

3. Universality: All insured residents are entitled to the same level of health care.

4. Portability: A resident that moves to a different province or territory is still entitled to coverage from their home province during a minimum waiting period. This also applies to residents which leave the country.

5. Accessibility: All insured persons have reasonable access to health care facilities. In addition, all physicians, hospitals, etc, must be provided reasonable compensation for the services they provide.

HEALTH CARE FUNDING Health care in Canada is funded at both the provincial and federal levels. The financing of health care is provided via taxation both from personal and

corporate income taxes. Additional funds from other financial sources like sales tax and lottery proceeds are also used by some provinces.

Alberta, British Columbia, and Ontario also charge health premiums to supplement health funding, but such premiums are not required for health coverage as per the Canada Health Act.

At a federal level, funds are allocated to provinces and territories via the Canadian Health and Social Transfer (CHST). Transfer payments are made as a combination of tax transfers and cash contributions. The amount of funding provinces and territories receive is significant, and topped $35 billion in 2002-2003.

In 2000, the new budget injected an additional $23 billion of investment into the health care system.

Approximately 11.2% of Canada's gross domestic product is spent on health care. In comparison, the United States spends close to 14% of its GDP on health care.

Individually, Canadians spend about $3300 per capita on health care. At a provincial level, funding is between one-third and one-half of what provinces

spend on social programs. About three-quarters of all funding comes from public sources, with the remainder

from private sources such as businesses and private insurance.

ACCESSING HEALTH CARE Accessing Canada's health care system involves first applying for

a provincial health card. There is a waiting period in place for new immigrants that cannot exceed three months.

Once a health card is assigned, it is used whenever visiting a physician or health care provider. The health card contains an identification number, which is used to access a person's medical information.

After obtaining health coverage, one can register with a primary care physician. For routine visits to a physician, one needs only present their health card. There are typically no forms to be filled out or individual service fees.

The availability of physicians depends largely on the number of doctors and the current demand for medical services. Currently there is about 1 primary care doctor for every 1000 Canadians.

PUBLIC HEALTH CARE PROVIDERS

Primary care physicians are the forefront of Canadian health care.

There are currently about 30000 primary care doctors in Canada, and they account for just over half of all physicians. They provide basic medical treatments and preventative care.

There are currently about 28000 specialist doctors working in Canada. An individual's physician will refer them to specialists as needed.

Hospitals operate both with referrals from physicians as well as on an emergency basis. Ambulatory services are provided for those unable to transport themselves to a hospital in the event of an emergency.

HEALTH CARE AND POLITICS One of the forefronts of debate in Canadian politics is its health care

system. There are many factors in the debate, but some key issues are: Federal involvement in health care: Because provinces and territories

are responsible for the actual administration and delivery of health care in Canada, friction is apparent whenever policies are set at a federal level.

Private health care: While privately funded clinics do provide certain services with shorter wait times than the public system, there are those who object to any privatization of the health system. The arguments are that a "two-tier" health care system will unbalance the system and favor those with higher incomes.

The shortage of doctors and nurses in Canada: Some feel that Canada's health care system does not adequately compensate health care providers. This has led to a "brain drain" of Canadian doctors and nurses, which have left Canada to pursue careers in the United States. Attracting and keeping skilled medical workers is a priority if Canada is to be able to provide proper medical services.

FIVE THINGS CANADIANS GET WRONG ABOUT THE HEALTH SYSTEM

A recent court challenge before the British Columbia Supreme Court threatened to change the rules of the game for the Canadian health care system – should the challenge have made its way to the Supreme Court of Canada and found success there. Dr. Brian Day of The Cambie Surgeries Corporation is contesting the ban against ‘extra billing’ for privately provided health services, and for the right of doctors to work simultaneously in both the public and private health spheres.

1. Doctors are self-employed, not government employees Canada has a publicly funded health care system, but the vast majority of doctors

do not work for the government. A patient is free to choose which doctor they wish to visit, and they are entitled to essential physician health services without charge. Doctors are self-employed, which means they can determine their own hours and work location, and they are responsible for paying their employees, for office space and other overhead expenses. Doctors earn money by billing their provincial government for the services they provide to patients.

The Canadian health system is often referred to as “socialized” medicine, but it is actually a mix of private providers billing governments for publicly funded services.

2. Canada has 15 different health care systems: People often refer to the “Canadian health care system,” when in reality, it has distinct health systems for each of the provinces and territories. The Canada Health Act outlines the basic tenets for health care to be universal and accessible for essential physician and hospital health services across the country. However, the details of how each system operates, including what is covered and how, is determined provincially. In addition, the federal government has responsibility for Aboriginal and veteran health care.

Add it together, and Canada has a whopping 15 unique health care systems. On the plus side, this means provinces can tailor health services to the particular needs of their residents; the downside is that co-ordinating health reforms across the country remains a significant challenge.

3. Funded health care services are not provided equally across the country The Canada Health Act guarantees that essential physician and hospital services

are paid for by the government, but there is variation across provinces for what is considered an “essential health service” – and even who delivers the care or where care is delivered.

For example, Quebec’s publicly funded system includes fertility treatments, while most other provinces do not. Some provinces, including British Columbia, Ontario and Quebec, pay for births delivered by licensed midwives, while several provinces and territories do not. Eligible funded therapies for autism vary widely across the country. Abortion services are not equally accessible across the country.

The Canada Health Act does not cover prescription drugs, home care or long-term care, and as a result, there are widely different approaches for these services in each province.

4. User fees charged to patients are not permitted Canadians cannot be charged a “user fee” when a physician provides an

insured service (something already covered by the publically funded health system). But some physicians get around the letter of the law by charging “annual fees” as part of a comprehensive package of services they offer their patients. Such charges are completely optional and can only be for non-essential health options.

In some provinces, doctors may charge a small fee to the patient for missed appointments, for doctor’s notes and for prescription refills done over the phone – all items for which a doctor receives no payment from the province.

5. Canada does not truly have a “single payer” system meaning a significant portion of Canadian health care comes from both public and private financing

Canada has extensive public financing for essential physician services and hospital care – among the highest rates in the world. But most Canadians have to pay for eye and dental care out-of-pocket, and more than 60 per cent of prescription medications are paid for privately in Canada.

Canada is the only country with a universal health care system that does not include prescription drugs. This means that Canadians still pay for approximately 30 per cent of their health care directly or via private insurance with only 70 per cent of health costs paid for publicly. In fact, Canadians are as likely to hold private health insurance as Americans.

Selected Rankings - 2016#6in the worldPopulation - Age 100+25,883 people

#13in the worldLife Expectancy81.85 years

Mortality Rates - 2016

· Life Expectancy 81.85 Years Rank: 13· Female 84.61 Years Rank: 13· Male 79.23 Years Rank: 14· Deaths Per 1000 8.54 Per 1,000 Rank: 83· Infant Mortality Rate 4.59 Per 1,000 Births Rank: 189· Female 4.25 Per 1,000 Births Rank: 187· Male 4.91 Per 1,000 Births Rank: 190· Mortality Rate - Age 1-4 0.70 Per 1,000 Births

Rank: 209· Female 0.63 Per 1,000 Births Rank: 204· Male 0.75 Per 1,000 Births Rank: 208· Mortality Rate - Under Age 5 5.28 Per 1,000 Births

Rank: 191· Female 4.88 Per 1,000 Births Rank: 189· Male 5.66 Per 1,000 Births Rank: 192

Birth Rates - 2016

·Gross Reproduction Rate 0.78 Per 1,000 Rank: 180·Ratio at Birth - Male to Female 1.06 Ratio Rank: 57·Total Fertility Rate 1.60 Births Per Woman Rank: 181·Fertility Rate· 15-19 13.80 Per 1,000 Women Rank: 178· 20-24 53.30 Per 1,000 Women Rank: 208· 25-29 101.90 Per 1,000 Women Rank: 187· 30-34 101.40 Per 1,000 Women Rank: 118· 35-39 41.70 Per 1,000 Women Rank: 149· 40-44 7.10 Per 1,000 Women Rank: 190· 45-49 0.30 Per 1,000 Women Rank: 221

Pro of Car in Canada: Access of Health Care for Everyone

In Canada anyone can get health care so this is a major advantage of this system. As long as the person is a resident of Canada they will receive some level of health care. People that are unemployed, student, disabled. Pensioners and so on can still get health care in Canada. This is usually the most talked about pro to universal health care and why it’s promoted so heavily.

Pro: Education programs Reduce Costs There are programs that work towards

preventing injuries and teaching citizens about health issues. There’s more public awareness about health risks and these programs are funded by the Government. These programs are created to help reduce health care costs and to teach people how to take control of their health before there are more serious problems. There are programs for seniors, those with disabilities, awareness campaigns for back injuries, and so on. These programs help people in Canada stay healthier because they get more education about health related issues.

Pro: Veterans are Looked After in Elder Years

The health care of veterans is well looked after in Canada and they get the care that they need in their later lives when they may be in care homes or seniors centers. The government just doesn’t treat injuries sustained in service of their country, the veterans get whatever care that they need.

Con: There can be Wait Times Most non-emergency surgeries will require

wait times. These wait times may put the patient at risk while they wait for a surgery or their condition may deteriorate as they wait. Those that need priority care make the wait times for others very frustrating. Seniors, those with life threatening conditions, and other urgent cases will be looked after first while others can sometimes wait a long time.

Con: Fees Don’t Take into Consideration Cost of Living

Health care providers are limited to what they can charge by the government. This limit can cap the earning potential of various providers and make it harder to pay back loans, limit their earning potential, and undermine their overall life. The limit of what they can charge may not keep pace with their cost of living.

Con: Those in Rural Areas May Not Get a Fair Share of Care

The health care revenues are redistributed according to demographics but the rural areas may not get the funding that they need to cover all costs like the larger cities do. The facilities in these location are improved at a slower rate which may require patients to go to city centers to get the care that they needs there can be a shortage of specialists and doctors in these areas.

CHALLENGES

Identifying and Acting on Shared Values Concerning Health

Shifting to Health from Health Care

Controlling Health Costs While Sustaining Health and Health Care

Organizing Health Providers and Health Services Appropriately

Measuring, Tracking and Reporting on Health System Performance

REFERENCES

www.theglobeandmail.com/globe-debate/five-things-canadians-get-wrong-about-the-health-system/article20360452/

www.canadian-healthcare.org/ healthycanadians.gc.ca/health-system-systeme-sante/system-

systeme/index-eng.php www.cpha.ca/en/programs/infrastructure.aspx www.canadian-hea1th www.canadian-healthcare.org www.hc-sc.gc.ca lthcare.org http://www.geoba.se/country.php?cc=CA&year=2016 2.www.hc-

sc.gc.ca 3.www.euro.who.int 4.publications.gc.ca