Health and Health Care Delivery in Canada PDF

Health and Health Care Delivery in Canada THIRD EDITION Valerie D. Thompson, RN, PHC, NP Former Professor, School of Health & Life Sciences and Community Services Professor/Coordinator, Health Ofﬁce Administration Programme, School of Business and Hospitality, Conestoga Institute of Technology and Advanced Learning Table of Contents Cover image Title page Copyright Dedication Preface Content Learning Features Acknowledgements Reviewers Special Features Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 Chapter 10 1: The History of Health Care in Canada Evolution of health care: an overview The introduction of health insurance Significant events leading up to the canada health act The canada health act (1984) After the canada health act: commissioned reports and accords Summary Review questions 2: The Role of the Federal Government in Health Care Health canada: objectives and responsibilities Health canada organization and structure Organizational structure of health canada Agencies of health canada Global organizations collaborating with health canada Summary Review questions 3: The Role of Provincial and Territorial Governments in Health Care Provincial and territorial health care plans Regionalization initiatives across canada Who pays for health care? Provincial/territorial roles Private and public health insurance Drug Plans Summary Review questions 4: The Dollars and “Sense” of Health Care Funding Funding versus the delivery of health care Levels of health care funding Expenditures for hospitals Continuing care in canada Continuing care: options The rising cost of drugs Health human resources Other health care cost drivers Conclusion Summary Review questions 5: Practitioners and Workplace Settings Categories of health care providers Regulation of health care professions Mainstream health care providers Practice settings Primary health care: issues and trends Summary Review questions 6: Essentials of Population Health in Canada Population health Introduction of population health to canada Determinants of health The population health approach: the key elements Population health promotion model Population health in canada and abroad Summary Review questions 7: Health and the Individual Health, wellness, and illness: key concepts Health models Changing perceptions of health and wellness The psychology of health behaviour The health–illness continuum The health of canadians today Summary Review questions 8: The Law and Health Care Laws used in health care legislation The law, the division of power, and the jurisdictional framework Health care as a right The legality of private services in canada Informed consent to treatment The health record Health care professions and the law Other legal issues in health care Summary Review questions 9: Ethics and Health Care What Is Ethics? Ethical Theories: The Basics Ethical Principles and the Health Care Profession Patients’ Rights in Health Care Ethics at work End-of-life issues Allocation of resources Other Ethical Issues in Health Care Summary Review Questions 10: Current Issues and Future Trends in Health Care in Canada Mental health and addiction Caring for an aging population Home and continuing care Drug coverage Indigenous health care Information technology and electronic health records The financial sustainability of health care in canada Summary Review Questions Appendix: Declaration of Alma-Ata Declaration Glossary Index Copyright ELSEVIER Health and Health Care Delivery in Canada, Third Edition ISBN: 978-1-77172-169-1 (Softcover) Copyright © 2020 Elsevier Inc. All Rights Reserved. Previous editions copyrighted 2010, 2016, Elsevier Canada, a division of Reed Elsevier Canada, Ltd. All rights reserved. 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The book and the individual contributions made to it are protected under copyright by the Publisher (other than as may be noted herein). Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent veriﬁcation of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors, or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence, or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. ISBN: 978-1-77172-169-1 VP Education Content: Kevonne Holloway Content Strategist (Acquisitions): Roberta A. Spinosa-Millman Director, Content Development: Laurie Gower Content Development Specialist: Sandy Matos Publishing Services Manager: Deepthi Unni Project Manager: Radjan Lourde Selvanadin Last digit is the print number: 9 8 7 6 5 4 3 2 1 Dedication To the memory of my beloved son, Spencer, who passed away in April 2017 and to his wife, Leigh, and their two little boys, Gregory and Severin Preface Valerie D. Thompson Individuals working in any facet of health care should understand the components of health and wellness and how health care is delivered in Canada. This unique text will provide a valuable overview of and foundation for understanding these important and challenging concepts. This book will also beneﬁt individuals wanting to better understand the essentials of health care delivery in Canada. While by no means exhaustive, Health and Health Care Delivery in Canada, Third Edition, discusses many components of health and health care delivery. The chapters in this edition have been updated and rearranged beginning with the history of health care in Canada. The proceeding chapters discuss the responsibilities of the various levels of government, the cost of health and illness, the current state of health human resources and the impact of population health initiatives from the perspective of the determinants of health. The concepts of health and illness follow which leads to an examination of the legal and ethical aspects of health care. The last chapter takes a critical look at current issues in health care as well as future trends. The book’s content has been carefully selected in order to highlight essential material. The chapter relate to and expand on content in the previous chapter. Common threads such as the determinants of health (in particular the effects of the social determinants of health) are carried throughout the book and material ﬂows in an orderly and understandable manner. Throughout this edition more emphasis on the health care challenges and needs of Indigenous people of Canada. It is important to note that this book provides a general overview, a snapshot of health and health care delivery in Canada, recognizing also that each jurisdiction delivers health care differently, and that changes are ongoing, thus currency in some areas is relative. By the end of this book, students will be able to say, “I understand health care issues in Canada and how different levels of government operate in terms of health care delivery. I understand how our health care system is funded and the future issues facing health and health care in Canada,” and, most important, “I understand the system that I am choosing to work in.” Intended to accompany postsecondary introductory courses in Canadian health care delivery, this book offers students a foundation with which they can easily move forward to other, more speciﬁcally focused courses. Content Chapter 1 (The History of Health Care in Canada) provides the reader with the highlights in the history of our health care system. These include the events leading up to the implementation of the Canada Health Act, which is the foundation of the health care system in Canada. Students are encouraged to examine the principles of this Act in terms of their relevance in the twenty-ﬁrst century. New to this chapter is an expanded section discussing the history of the health and healing practices of Indigenous Peoples in Canada from the “precontact” era to present day. Chapter 2 (The Role of Health Canada and Other Federal and International Health Agencies) and Chapter 3 (The Role of Provincial and Territorial Governments in Health Care) focus on the division of powers and the implementation of health care from federal and provincial or territorial levels. Chapter 2 explores recent changes in the organizational structure of Health Canada such as the newly created Opioid Response Branch and the Cannabis Legalization and Regulation branch. Chapter 3 follows three families—two of whom are new to Canada addressing the challenges and barriers they face settling in a new country and understanding a new healthcare system. Most students are likely to have had some exposure either direct or indirect to individuals seeking a new life in Canada and will be better able to relate to and appreciate the challenges involved with such things as ﬁnding a physician, navigating the healthcare system, and understanding what is covered under their provincial/territorial plan. This chapter highlights some variations in the provincial and territorial health care plans how health care is delivered, and how these differences affect the families. For example, in 2 019 the government of Ontario changed the structure and functional aspects of how health care is delivered. Educators are encouraged to expand on health care delivery in their own jurisdictions while comparing it with those of other jurisdictions. Chapter 4 (The Dollars and “Sense” of Health Care Funding) looks at current ﬁnancial issues, where the money for health care comes from where it goes, and also examines what “strings” the federal government attaches to its funding for the provinces and territories. This chapter includes a discussion about the targeted funding for mental health and home care services designated by the federal government in the 2017 budget, and the speciﬁc funding arrangements made by each jurisdiction. The major cost drivers regarding prescription drugs and the current status of a proposed national pharmacare program are also addressed. Chapter 4 examines the sobering fact that real-life health care decisions are sometimes made based on who qualiﬁes for treatment under a provincial or territorial plan and who does not—and who will opt to pay for services out-of-pocket. Chapter 5 (Practitioners and Workplace Settings) provides the student with a clear picture of the current state of our health human resources—who delivers the care, in what setting, and under what circumstances. It examines how the delivery of primary healthcare has changed across Canada in terms of primary health care teams which operate under numerous delivery models and the expanding roles and responsibilities of various health care providers. Chapter 6 (The Essentials of Population Health in Canada) explains how the government and other health care stakeholders evaluate the health of Canadians, identify risk factors, implement strategies to deal with current health problems, and predict problems that are likely to arise in the future. Population health initiatives are discussed from the perspective of the determinants of health, particularly the social determinants and their sometimes- devastating effects on vulnerable population groups. Chapter 7 (Health and the Individual) provides the student with an understanding of the key concepts of health, wellness, illness, disease, and disability. In this edition, spiritual and emotional wellness are emphasized along with holistic interventions and models of wellness. The concept of the Indigenous “wholistic” theory framework which incorporates the medicine wheel along with the w/holistic concept of understanding the nature of balance, harmony, and living a good life. Among other things, students are encouraged to examine their own health beliefs and health behaviours and to consider how these contribute to maintaining health. Chapter 8 (The Law and Health Care) analyzes legal issues, clarifying provincial, territorial, and federal boundaries in terms of legislation and the law. Considerable discussion is devoted to current laws regarding conﬁdentiality and consent to treatment. Included in this chapter is a discussion surrounding the legal aspects of medical assistance in dying and the use of both medical and recreational cannabis. Chapter 9 (Ethics and Health Care) highlights ethical principles and points out that health care professionals are held to a higher level of ethical accountability than are those in many other professions. This chapter also discusses the ﬁne line that sometimes divides ethics and health-related legal issues such as medical assistance in dying and the use of cannabis. The student will learn why this boundary is so fragile and how to practise in a moral and ethical manner. Legal implications retarding the current opioid crisis in Canada are also discussed Chapter 10 (Current Issues and Future Trends in Health Care in Canada) discusses important challenges currently facing Canada’s health care system, such as the state of mental health services, managing care for Canada’s aging population, the shortage of human health resources, and the increasing need for home care services. This chapter also contains an expanded discussion on the health of Indigenous People of Canada, disparities that affect their health and well-being, current challenges many Indigenous population groups face, and health care services available. Additionally, this chapter explores other issues that will impact the future of health care in Canada. This includes the risks and beneﬁts involving the safety/security of electronic health information and the impact of social media on health care. How can Canada maintain adequate health care services in the face of complex medical problems, increasingly expensive drugs, advancing and costly technology, and less funding? Will electronic medical records and electronic health records be implemented at a national level, and how and when will this implementation take place? Although no concrete answers exist, the student will be prepared to look ahead, aware of the signiﬁcant obstacles that we as a nation must overcome if we are indeed to salvage publicly funded health care for all. Learning Features Each chapter contains several unique features meant to stimulate student interest. Learning outcomes outline the objectives for the chapter. Key terms deﬁne challenging concepts. Chapter summaries and review questions underscore key elements. Additional features include general interest, “Thinking It Through,” “Did You Know?,” and “Case Example” boxes. These features encourage the student to think through facts, points of interest, and actual situations and to answer questions that promote exploration of personal views, general discussion, and, in some cases, further investigation. Additional Evolve® online resources to accompany the text can be found at http://evolve.elsevier.com/Canada/Thompson/health. Acknowledgements Writing a book of this nature cannot possibly occur in isolation. I owe a great deal to so many people, including those working with the Canadian Institute for Health Information and Health Canada. Thanks also to Judith Surridge, BScN Woman’s College Hospital, and Dr. James McArthur for sharing his knowledge and expertise regarding treatments and supports available for those misusing opioids and other drugs. I owe a debt of gratitude to Lynda Cranston, substantive editor, for her meticulous review, organizing and editing of numerous chapters, and to Ellen Hawman for her assistance in researching and citing resources throughout the book. I’d also like to acknowledge Lyle Grant for his detailed and expert legal review of Chapter 8. Special thanks to the Elsevier team that have been supportive throughout all editions of the textbook. A very special thank you to Sandy Matos, Development Editor, for her patience, knowledge, and support throughout the writing and preparation of the third edition. I would like also to acknowledge and thank Elsevier’s reviewers, who provided helpful comments, constructive criticism, and suggestions for improvements during various stages of the manuscript. I am grateful for the advice and recommendations provided to me, much of which was used to prepare this third edition. Reviewers Sharon Demers, RN BN, CAE Instructor, Practical Nursing Qualiﬁcation Recognition Program, Assiniboine Community College, Winnipeg, MB Tracy Hoot, RN, BScN, MSN, DHEd Associate Dean, School of Nursing, Thompson Rivers University, Kamloops, BC Laureen Larson, MHRD, PMP, BVTEd, BScN, RN Occupational Health Nursing Academic Chair – Addictions Counselling, Health Information Management, Occupational Health Nursing, and Psychiatric Nursing Programs; Indigenous Nursing and Inter-Professional Education Services School of Nursing, Saskatchewan Polytechnic, Saskatoon, SK Tammie McParland, RN, PhD, CCNE Director and Assistant Professor, Faculty of Education & Professional Studies, School of Nursing, Nipissing University, Nipissing, ON Kathlyn Palafox, BSN, BCPID Academic Instructor, West Coast College of Massage Therapy, New Westminster, BC Andria Phillips, RN MScN CCNE Sessional Lecturer, School of Nursing, Faculty of Health, York University, Toronto, ON Professor Kari Rivest, MRT (R), BSc Medical Radiation Technology Program, School of Health Sciences and Emergency Services, Cambrian College, Sudbury, ON Beverley Robinson, MA Social Work Lecturer, School of Continuing Studies, McGill University, Montreal, QC Isabelle Wallace, RN, BScN, MScN Director, Dialogue NB, Moncton, NB Lead Analyst, Indigenous Policy and Research, New Brunswick Health Council - Conseil de la santé du Nouveau-Brunswick, Moncton, NB Chris Watkins, RPN, Dip PN, BScPN, MN Assistant Professor, Psychiatric Nursing Program, MacEwan University, Edmonton, AB Special Features Chapter 1 Did You Know? (p. 5) Box 1.1 Residential Schools (p. 6) Thinking It Through (p. 6) Box 1.2 Innovation in Newfoundland: The Cottage Hospital System (p. 7) Did You Know? (p. 9) Thinking It Through (p. 9) Thinking It Through (p. 14) Thinking It Through (p. 14) Box 1.3 Legislation Leading up to the Canada Health Act (p. 15) Box 1.4 Eligibility for Health Care under the Canada Health Act (p. 16) Box 1.5 The Primary Objective of Canadian Health Care Policy (p. 16) Box 1.6 The Canada Health Act: Criteria and Conditions (p. 17) Case Example 1.1 (p. 17) Case Example 1.2 (p. 18) Case Example 1.3 (p. 19) Case Example 1.4 (p. 19) Case Example 1.5 (p. 19) Case Example 1.6 (p. 19) Thinking It Through (p. 20) Case Example 1.7 (p. 21) Box 1.7 Alternative Health Care Strategies (p. 22) Table 1.1 The Goals of Primary Care Reform (p. 23) Box 1.8 Three Major Reports on the Status of Health Care in Canada (p. 24) Thinking It Through (p. 27) Did You Know? (p. 29) Chapter 2 Thinking It Through (p. 38) Did You Know? Jordan’s Principle (p. 40) Box 2.1 The First Ever Food Guide for First Nations, Inuit, and Métis (p. 42) Did You Know? (p. 42) Did You Know? Health Canada Gives Permission for New Product (p. 44) Thinking It Through (p. 44) Box 2.2 Canadian Institutes of Health Research (CIHR) Institutes Across Canada (p. 46) Thinking It Through (p. 48) Did You Know? (p. 48) Box 2.3 The World Health Organization: The Six-Point Agenda (p. 49) Thinking It Through Ethical Use of Vaccines (p. 54) Chapter 3 Case Example 3.1 (p. 57) Case Example 3.2 (p. 58) Case Example 3.3 (p. 58) Box 3.1 The Constitution Act: A Clariﬁcation (p. 58) Case Example 3.4 Levels of Care (p. 61) Box 3.2 Regional Health Authorities: A Deﬁnition (p. 61) Thinking It Through (p. 68) Case Example 3.5 (p. 70) Case Example 3.6 (p. 70) Case Example 3.7 (p. 71) Box 3.3 Reciprocal Agreement (p. 71) Thinking It Through The Arrival of a Syrian Family (p. 71) Did You Know? (p. 72) Box 3.4 Private Clinics: Concerns (p. 75) Box 3.5 Uninsured (Chargeable) Versus Insured Physician Services (p. 77) Thinking It Through (p. 77) Case Example 3.8 (p. 78) Case Example 3.9 (p. 78) Case Example 3.10 (p. 81) Thinking It Through (p. 82) Chapter 4 Box 4.1 Equalization Payments Embedded in the Canadian Constitution (p. 88) Table 4.1 Provincial and Territorial Health Spending per Capita: 2017 (Estimated) (p. 89) Thinking It Through (p. 90) Thinking It Through (p. 93) Table 4.2 National Average Cost of Procedures and Conditions for Inpatients of All Age Groups, Based on the Average Total Length of Stay, 2014–2015 (p. 95) Case Example 4.1 (p. 96) Case Example 4.2 (p. 101) Case Example 4.3 (p. 102) Case Example 4.4 (p. 105) Chapter 5 Table 5.1 Some of Canada’s Health Care Providers (p. 115) Thinking It Through (p. 116) Table 5.2 Regulated Health Care Professions in Each Province and Territory (p. 118) Box 5.1 Regulated Professions: Common Elements (p. 120) Thinking It Through (p. 121) Case Example 5.1 (p. 122) Case Example 5.2 (p. 123) Case Example 5.3 (p. 123) Case Example 5.4 (p. 126) Case Example 5.5 (p. 128) Did You Know? (p. 132) Thinking It Through (p. 133) Case Example 5.6 (p. 138) Case Example 5.7 (p. 138) Thinking It Through (p. 139) Did You Know? (p. 140) Case Example 5.8 (p. 142) Case Example 5.9 (p. 145) Thinking It Through (p. 146) Case Example 5.10 (p. 146) Case Example 5.11 (p. 147) Chapter 6 Box 6.1 Population Health Versus Public Health (p. 152) Did You Know? (p. 152) Box 6.2 Alma-Ata Deﬁnition of Primary Health Care (p. 154) Thinking It Through (p. 154) Thinking It Through (p. 154) Case Example 6.1 (p. 155) Box 6.3 Socioeconomic Status Explained (p. 156) Box 6.4 Strategies for Improving the Health of Canadians (p. 157) Thinking It Through (p. 158) Did You Know? (p. 159) Case Example 6.2 (p. 160) Case Example 6.3 (p. 160) Thinking It Through (p. 160) Did You Know? (p. 161) Thinking It Through (p. 162) Thinking It Through (p. 163) Did You Know? (p. 164) Did You Know? (p. 165) Did You Know? (p. 166) Thinking It Through (p. 168) Thinking It Through (p. 168) Box 6.5 An Aging Population: An Example of Population-Based Surveillance (p. 170) Chapter 7 Box 7.1 Health: An Evolving Deﬁnition (p. 181) Thinking It Through (p. 184) Thinking It Through (p. 185) Box 7.2 People With Disabilities: Rights Are Formally Recognized (p. 186) Did You Know? Terry Fox: A Continuing Legacy (p. 186) Thinking It Through (p. 188) Thinking It Through (p. 191) Case Example 7.1 (p. 191) Case Example 7.2 (p. 194) Case Example 7.3 (p. 195) Did You Know? Medical Assistance in Dying in Canada (p. 195) Case Example 7.4 (p. 196) Case Example 7.5 (p. 197) Thinking It Through (p. 198) Box 7.3 Stages of Illness (p. 198) Table 7.1 Life Expectancy at Birth, 2014–2016 (p. 200) Did You Know? Calculating Infant Mortality (p. 200) Chapter 8 Box 8.1 Equality of Care for Hearing Impaired People (p. 210) Case Example 8.1 (p. 211) Box 8.2 Strategies for Avoiding Legal Problems (p. 212) Case Example 8.2 (p. 213) Did You Know? (p. 216) Case Example 8.3 (p. 216) Thinking It Through (p. 216) Did You Know? (p. 218) Thinking It Through (p. 218) Thinking It Through (p. 222) Thinking It Through (p. 224) Case Example 8.4 (p. 225) Thinking It Through (p. 225) Case Example 8.5 (p. 228) Did You Know? (p. 230) Box 8.3 Conﬁdentiality: An Age-Old Concept (p. 234) Case Example 8.6 (p. 235) Case Example 8.7 (p. 240) Chapter 9 Case Example 9.1 (p. 247) Case Example 9.2 (p. 248) Thinking It Through (p. 248) Case Example 9.3 (p. 249) Thinking It Through (p. 250) Thinking It Through (p. 251) Case Example 9.4 (p. 252) Did You Know? (p. 253) Box 9.1 A Modern Version of the Hippocratic Oath (p. 255) Thinking It Through (p. 256) Case Example 9.5 (p. 256) Thinking It Through (p. 259) Did You Know? (p. 261) Did You Know? Medical Assistance in Dying (p. 261) Case Example 9.6 The Latimer Tragedy (p. 262) Thinking It Through (p. 262) Thinking It Through (p. 264) Case Example 9.7 (p. 265) Case Example 9.8 (p. 267) Thinking It Through (p. 268) Case Example 9.9 (p. 268) Thinking It Through (p. 268) Thinking It Through (p. 271) Thinking It Through (p. 271) Chapter 10 Thinking It Through (p. 280) Thinking It Through (p. 285) Case Example 10.1 (p. 288) Did You Know? (p. 289) Thinking It Through (p. 289) Did You Know? (p. 290) Thinking It Through (p. 291) Did You Know? (p. 293) Box 10.1 The Sioux Lookout Meno Ya Win Health Centre (p. 297) Did You Know? (p. 297) Thinking It Through (p. 300) Case Example 10.2 (p. 303) 1 The History of Health Care in Canada I came to believe that health services ought not to have a price tag on them, and that people should be able to get whatever health services they required irrespective of their individual capacity to pay. Tommy Douglas LEARNING OUTCOMES 1.1 Summarize the early evolution of health care in Canada. 1.2 Explain the effects of colonization on Indigenous peoples’ health practices and ceremonies. 1.3 Discuss the introduction of public health insurance. 1.4 Describe signiﬁcant events and legislation shaping health care from 1960 until the introduction of the Canada Health Act (CHA) in 1984. 1.5 Understand and discuss the terms and conditions of the Canada Health Act. 1.6 Explain the events that have occurred since the implementation of the Canada Health Act, including commissioned reports and accords. 1.7 Summarize agreements, accords, and other health legislation enacted since the year 2000. KEY TERMS Aseptic technique Block transfer Canada Health Act Catastrophic drug costs Delisted Eligible Extra billing First ministers Health accord Medically necessary Medicare Palliative care Prepaid health care Primary health care reform Quarantine Refugee claimants Royal assent Social movements User charges Tommy Douglas (1904–1986) was considered by many to be the father of medicare in Canada. One can’t help but wonder what advice he would have for Canadians today regarding the sustainability of medicare, how to manage it, and how to ensure that our publicly funded system can continue to equitably meet the needs of all Canadians. This chapter will look at the evolution of the Canadian health care system as it existed before Confederation, how it has evolved into what it is today, and what challenges the system is faced with to remain viable for the future. The chapter will address the nature of health care for the Indigenous population, the traditions and ceremonies they practised, and the devastating effects colonization had on their health care system. The effects of social, economic, and technological growth has dramatically transformed health care in Canada over the past century. Every decade has brought changes to where and how people live, their views of and responses to illness, in addition to the kind of treatment they both need and expect. This includes adapting to meet the needs of new Canadians in a knowledgeable and culturally sensitive manner. According to the United Nations High Commission for Refugees (UNHCR) Canada welcomed over 46,000 refugees in 2016, compared to 24,070 in 2014 and 32,115 in 2016 (UNHCR, 2017). This surge in immigration required volunteers, health care providers, community agencies, and other stakeholders to work together to help these refugees adapt to life in Canada, which included meeting their health care needs. Immigrants came from different countries such as Eritrea, Iraq, Congo, and Afghanistan. The largest number of refugees came from Syria with over 33,000 new Canadians. As you read this chapter, note continuing parallels between the needs of the population and the adaptation and growth of health care services, including primary care in your own jurisdiction. Do the majority of Canadians in your region have a family physician or a nurse practitioner? Are you part of a primary health care multidisciplinary team? Are primary care services, home care, and community care services adequate? When you reach the end, think about the terms and conditions of the Canada Health Act in particular, and ask yourself if the Act still meets the needs of Canadians. Is our health care universal? Is health care accessible to all? Is it provided to all Canadians on uniform terms? Is it delivered in a timely fashion to all? Continued debate about the quality and availability of health care has generated repeated demands for system improvements and for increases in dedicated funds. Does the Canada Health Act need to be changed, or do the expectations and attitudes of Canadians need to be adjusted? Write down your thoughts about these questions before you continue reading, and then compare your thoughts with those shared in this chapter. Evolution of health care: an overview With the passage of the British North America Act in 1867 (renamed the Constitution Act in 1982), Confederation became a reality. The Dominion of Canada consisted of Ontario and Quebec (formerly Upper and Lower Canada, respectively), New Brunswick, and Nova Scotia, and Sir John A. Macdonald was the Dominion’s prime minister. Each province had its own representation in government, its own law-making body (which evolved into a provincial government), and its own Lieutenant Governor to represent the Crown. The British North America Act also established a federal government comprising the House of Commons and the Senate—the same structure in place today. The ﬁrst census for the new Dominion in 1871, showed a population of 3 689 257—a large enough number to warrant closer attention to people’s health care needs. Legislation regarding responsibilities for health care was vague at best, but even at this early stage responsibilities were divided between the federal and provincial governments. Division of Responsibilities for Health Health matters received little attention in the British North America Act. The federal government was charged with responsibilities for the establishment and maintenance of marine hospitals, the care of Indigenous populations, and the management of quarantine. Relatively common, quarantines were imposed to prevent outbreaks of such diseases as cholera, diphtheria, typhoid fever, tuberculosis (TB), and inﬂuenza, and this remains the case today in the face of current infectious outbreaks discussed in Chapter 6. Provinces were responsible for establishing and managing hospitals, asylums, charities, and charitable institutions. Many of the provincial responsibilities regarding health care—including social welfare, which, broadly speaking, encompassed health and public health matters—were assumed by default since they were not clearly outlined in the Act as federal responsibilities. Today the federal government retains responsibility for health care for most Indigenous communities (on reserves), some members of the RCMP, the armed forces, people detained by Correctional Services, and veterans. As of April 2013, regular members of the RCMP have been covered for basic health beneﬁts by the province or territory in which they live (see Chapter 3). Under the Interim Federal Health Program (IFHP), the federal government also pays for temporary health insurance for selected refugee claimants, discussed in more detail in Chapter 7. In 1919, the federal government created the Department of Health, largely to assume its health-care-related responsibilities, which included working collaboratively with the provinces and territories in health care matters and promoting new health care initiatives. (From 1867 to 1919, federal health concerns were managed by the Department of Agriculture.) Early projects undertaken by this new department reﬂected the issues faced by Canadians at that time— speciﬁcally, the increase in sexually transmitted infections (STIs) and the recognition of the importance of keeping children healthy and safe. In response, venereal disease clinics were established across the country, and campaigns promoting child welfare were launched. In 1928, the Department of Health became known as the Department of Pensions and National Health. The name changed again in 1944 to the Department of National Health and Welfare, and federal responsibilities expanded to include food and drug control, the development of public health programs, health care for members of the civil service, and the operation of the Laboratory of Hygiene (a precursor to Canada’s current Laboratory Centre for Disease Control). In 1993 the department was renamed Health Canada. The federal government also retains responsibility for health coverage for certain population groups (discussed in Chapter 2). The Origins of Medical Care in Canada The ﬁrst doctors in Canada, a combination of civilian and military physicians, came with the arrival of European settlers (primarily from England and France). These doctors cared for the sick at home and then in hospitals once they were built. In the eighteenth century and early nineteenth century, only the wealthier settlers were able to afford medical attention from a doctor and to seek care in a hospital when required. The less fortunate received care through religious and other charitable organizations, or from family and friends, who provided in-home care using botanical remedies and other natural medicines shared with them by Indigenous peoples. Canada’s ﬁrst medical school was established in Montreal in 1825. By the time of Confederation, the country had a steadily increasing number of doctors, hospitals, and medical schools, resulting in medical and hospital care that was more accessible to all sectors of the population. The History of Healing Practices of Indigenous Canadians Health and healing ceremonies practised by Canada’s Indigenous population date back centuries. The information surrounding these rituals, ceremonies, and practices has been passed down from one generation to another both orally and through ‘hands on’ experiences (e.g., from one healer to another). Very little information was actually documented, resulting in few written resources. Many of the healers and elders with knowledge about cultural and healing practices died during epidemics and from diseases introduced by non-Indigenous people. The large numbers of deaths and ultimately the collapse of many population groups nearly eradicated the Indigenous health care system. Most cultural practices were rooted in holistic and spiritual beliefs along with an integral relationship with nature and “Mother Earth.” Indigenous healers went by many names including the “Medicine Man” and the “Shaman.” There were also midwives (also known as life-givers, typically women), spiritual and herbal healers. The role of healer was not exclusive to men; in fact in many Indigenous cultures, women had long been recognized as powerful healers. History indicates that prior to contact with Europeans (sometimes referred to as the precontact era) Indigenous people were very healthy. They led an active lifestyle and ate a healthy diet—sources of food were from the land: hunting, ﬁshing, and harvesting local vegetation (most bands moved to maximize seasonal food sources). The few illnesses Indigenous people had were sometimes attributed to evil spirits, or an imbalance or disharmony between such entities as the body, mind, community, and nature. For example, oral history indicates that Indigenous people had arthritis and jaw abscesses. Like many traditions, an understanding of healing and the use of herbal medicines was passed down through generations via oral teachings and observances. A variety of rituals, ceremonies, and spiritual practices were used to treat some of these disorders, whereas other disorders were treated with a variety of plants, herbs, roots, and fungi. For example, Indigenous healers used the bark of the willow tree—which contains the same active ingredient in aspirin—to treat headaches. Parts of the dandelion were used for skin ailments such as boils, abscesses, rashes, and inﬂamed joints. Even gooseberries helped with constipation. Today many traditional medicines have been incorporated into contemporary Western medicinal practices. Traditional rituals and spiritual ceremonies include the sweat lodge, healing circle, smudging ceremonies, and the Medicine Wheel —many are still used today. Each of the rituals is described below to explain the holistic and spiritual nature of traditional healing practices. Please note that elements of these ceremonies differ from one group to another. The sweat lodge was one of the most valued methods of traditional healing and it is still used by many communities today. It is a cleansing and healing ceremony. In preparation for the ceremony the person or persons being treated must fast (up to 4 days) thus depriving the physical self of food and water. This is thought to weaken the (powerful) physical self and rendering the person vulnerable thus more receptive to advice and teachings from the spirit world. The sweat lodge itself is dome shaped, specially constructed, and the ceremonies are complex. The desired outcome is to have those who are participating in the ceremony pushed to their limit both physically and emotionally. This occurs when they endure long periods in the extreme heat generated within the sweat lodge. This enabled the person’s spiritual self to receive messages from the spirit world (or the creator) and complete the ceremony with a renewed sense of self and life’s direction. It must be noted that although the ceremony was most often associated with cleansing and healing, ceremonial leaders could assign a different purpose to each ceremony; for example, to work out any family issues and in more recent years, deal with addictions (e.g., alcohol/drug). The conﬁguration of the healing circle was structured to promote open communication. Participants include individuals who were dealing with difﬁculties and problems in their everyday lives. This ceremony sometimes began with smudging—the burning of medicine such as sage or sweetgrass. Smudging requires that participants sweep the smoke towards their faces (eyes, ears, mouth) and all over their bodies. The smoke is supposed to help participants to see, hear, and understand things in a positive manner; speak wisely, carefully, and truthfully; and create a loving environment. Often individual prayers are followed by a group prayer that is said to be carried to the creator by the smoke. Then a facilitator makes group introductions and explains the rules and how the session will be conducted. For some ceremonies the facilitator passes out an eagle feather or a stick. The person who has possession of the feather or stick is allowed to speak. Everyone is offered the chance to speak. The healing circle is very similar to a therapy session. There must be a skilled facilitator who leads the session, carefully monitoring what is being said, and leading the discussion. The exact structure of the medicine wheel varies. Basically, the wheel represents four parts of a person—spiritual, physical, cognitive, and emotional. The person must acknowledge responsibility for themselves in all categories to regain total health. The circle represents continuous movement and connectivity. Did You Know? The Eagle Feather has signiﬁcant spiritual signiﬁcance in First Nations culture. The eagle is considered sacred as it ﬂies higher than other birds, thus closer to the creator. The feather has been adopted by courts in several jurisdictions as an alternative to using the bible when Indigenous people are testifying under oath in court-related occurrences (afﬁrmation or oath swearing). The move is to make the legal process more culturally acceptable for Indigenous people. In October 2017, the RCMP in Nova Scotia adopted this practice at the detachment level (a ﬁrst in Canada for the RCMP). Sources: Rice, W. (January 18, 2016). Eagle feathers now on hand for oaths at Ottawa courthouse. Retrieved from http://www.cbc.ca/news/canada/ottawa/eagle-feathers-now-on- hand-for-oaths-at-ottawa-courthouse-1.3409212; Royal Canadian Mounted Police. (October 27, 2017). Media Advisory: Nova Scotia RCMP to unveil eagle feather initiative. Retrieved from www.grc.gc.ca/en/news/2017/media-advisory-nova-scotia-unveil- eagle-feather-initiative; Thatcher, A. (October 3, 2017). Eagle feather ﬂies into Nova Scotia detachments. Gazette (Vol. 79, No. 4). Retrieved from www.rcmp-grc.gc.ca/en/gazette/eagle-feather-ﬂies-nova- scotia-detachments. Contact With Outsiders Some of the earliest contacts were in the 1700s with Russian, French, Spanish, and British traders, explorers, as well as settlers. Contact in the interior was primarily with traders who worked for the Hudson’s Bay Company. They brought with them numerous diseases previously unknown to this part of the world. Indigenous people had no natural immunity to these diseases, let alone any traditional treatments. Such illnesses included smallpox, tuberculosis, inﬂuenza, whooping cough, and measles. The effect on the Indigenous population was disastrous, resulting in the death of thousands. Traditional rituals and practices remained largely ineffective in treating these conditions. The smallpox vaccine discovered at the turn of the century was rarely available to the Indigenous population. The British North American Act (1867) and the India Act (1876) set the stage for the assimilation of Indigenous people, applying numerous restrictions to their practices and way of life. The inability of Indigenous healers to successfully treat the newly introduced diseases allowed non-Indigenous people to discredit traditional healing ceremonies and the legitimacy of traditional healers. Subsequent amendments to the Indian Act legally banned most Indigenous spiritual and health related rituals, ceremonies, and practices until the 1950s and beyond. Over the next several decades, Indigenous people in Canada lost most of their cultural norms. They suffered from the devastating effects of being in residential schools and their suffering continues today impacting their physical and mental health. For more about residential schools see Box 1.1. Recently Western medical practices have largely replaced traditional healing. Health services that are provided in more geographically isolated communities are often limited in staff and supplies, and at times don’t meet the criteria outlined in the Canada Health Act. Few of the goals and standards outlined in Health Canada’s determinants of health have been met and remain a growing concern. Box 1.1 Residential Schools. Residential Schools were church-run boarding schools, funded by the federal government, which essentially assumed custodial rights of Indigenous children. The goal was to assimilate Indigenous youth into what was considered Canadian society and culture. One of the ﬁrst schools opened in 1831 in Brampton, Manitoba, and the last one closed in Punnichy, Saskatchewan 1996, long after the horrors and injustices these children suffered were well known (an estimated 150 000 children). Children were torn from their families and communities, stripped of their identities, language, and culture. They were subjected to varying levels and types of abuse. Mistreatment, inadequate nutrition, and denial of proper care also resulted in the deaths of many of the children. The Indian/Indigenous Residential Schools Settlement in 2007 resulted from lobbying and pressure from Indigenous people who had attended residential schools; this was followed by a formal apology by then Prime Minister Harper in 2008. The settlement acknowledged the suffering and resulting damage done to former students, and established a multimillion-dollar fund for individual compensation packages to help former students seek treatment, and work towards recovery through, among other resources, the Aboriginal/Indigenous Healing Foundation. The settlement also included the establishment of the Indian/Indigenous Residential Schools Resolution Health Support Program also meant to provide support for those suffering mental health and emotional trauma. Providers include a multidisciplinary team of health care workers including Indigenous elders, social workers, and psychiatrists. The settlement was not without problems and criticisms regarding unethical use of the money and unethical fees charged by lawyers. Note that this information, far from complete, is a brief overview of components of the residential school system and its effects on the Indigenous community. Source: First Nations Health Authority. (n.d.). Our history, our health. Retrieved from http://www.fnha.ca/wellness/our-history-our- health. However, there are recent movements to return the responsibility of health care to Indigenous communities and to honor the value of traditional health practices. Many hospitals, clinics, and community health centres now integrate traditional health practices with western medical practices (see Chapter 10). Today the conditions most affecting Indigenous populations include diabetes, heart disease, cancer, mental illness, and addictions to drugs and alcohol. The medicine practised by Indigenous people in North America has a long and rich history. Sometimes referred to as shamans or medicine men (note that the role of healer was not exclusive to men; in many Indigenous cultures, women have long been recognized as equally powerful healers), traditional Indigenous practitioners were believed to have a strong connection to the spirit world and to Mother Earth. Many of the shaman’s teachings and remedies attempted to maintain balance and harmony among spiritual and natural elements and the human populations that depended on these elements for survival. Current issues and trends related to Indigenous health are discussed in Chapter 10. Thinking it Through Health professionals should be knowledgeable about health-related traditions and cultural practices that are important to their patients. Honouring such practices whenever possible will contribute to a positive patient experience, improve patient adherence, and contribute to the patient’s well-being. 1. Are there individuals or groups of people within your community who would beneﬁt from culturally speciﬁc approaches to health care? 2. Considering cultural traditions or practices, identify three ways in which you could improve a patient’s experience in a health care setting in your community. The Development of Hospitals in Canada An order of Augustinian nuns from France who worked as “nursing sisters” established Canada’s ﬁrst hospital, the Hôtel-Dieu de Quebec, which opened in Quebec City in 1639. The nuns set up several other hospitals in the days before Confederation. In fact, with government funding often limited and unreliable, all of Canada’s early hospitals were charitable institutions that relied on ﬁnancial support from wealthy people and well-established organizations. It was not until the already-established Toronto General Hospital closed from 1867 to 1870 due to lack of funds that the Ontario government passed an act providing yearly grants to hospitals and other charitable institutions, laying the groundwork for the present- day provincial government funding of hospitals. Hospitals of the early 1800s were crowded places focused on treating infectious diseases, primarily among people of the poorer classes who could not afford private care. By contrast, the wealthier segment of the population avoided hospitals by hiring doctors who would visit patients’ homes to provide treatment. With the introduction of anesthesia, aseptic technique, and improved surgical procedures in the 1880s, however, hospitals were ﬁnally regarded as places to go to get well, and the use of hospital facilities increased. In the early 1900s, tuberculosis sanitariums were developed to isolate and care for tuberculosis patients. The disease was difﬁcult to treat, with surgical removal of diseased organs often the only viable cure, and many tuberculosis patients died in hospital. Special institutions to care for mentally ill people were also established. Because of the shame associated with mental illness at the time, those who suffered from it were often forcibly admitted to these institutions by family members. Most patients never emerged. With grants from federal and provincial governments and advances in medical care, the number of hospitals increased over the next several decades. Physician and hospital services remained out- of-pocket expenses for patients, although some had insurance protection through their employers. Charitable and religious organizations continued to assist those who could not afford care. During this time, governments made some efforts to improve access to medical care and to provide an affordable fee structure for it (Box 1.2). Box 1.2 Innovation in Newfoundland: The Cottage Hospital System. In the 1930s approximately 1 500 communities in Newfoundland were scattered across 7 000 miles of coastline. To service these communities the provincial government developed the Cottage Hospital and Medical Care Plan in 1934, which funded the building of a network of small hospitals and paid doctors and nurses to travel to port communities along the extensive coastline. One hospital was even built on a boat. Intended primarily to provide outpatient care, these small hospitals were equipped with minimal inpatient facilities (20–30 beds), an operating room, diagnostic facilities, and a well-equipped emergency department. Outpatient services offered included immunizations, prenatal and infant care, and patient follow-up at home. The hospitals were staffed mostly by physicians and nurses with surgical and emergency care experience, and an annual fee of $10 provided a family with health care and use of the cottage hospitals, including transfer to the nearest base hospital when necessary. Not only was Newfoundland’s cottage hospital system innovative and progressive for its time, but also to this day, provincial and territorial systems draw on some of its key elements, such as small clinics for rural communities. Source: Connor, J. H. T. (2007). Twillingate: Socialized medicine, rural doctors, and the CIA. Newfoundland Quarterly,100(424). Retrieved from http://www.newfoundlandquarterly.ca/issue424/twillingate.php. Segregated Hospitals for Indigenous People What was then termed “Indian” hospitals were initially operated by churches in the late 1800s. After the Second World War the federal government’s Department of Health and Welfare expanded a system of separate hospital care for Indigenous people. Some new facilities built were free standing hospitals, others were refurbished military barracks, “out-buildings,” or annexes afﬁliated with other hospitals. The facilities overall were underfunded, inadequately equipped, maintained, and staffed (e.g., kitchen and laundry facilities, few nurses/patient numbers, poor heating). Initially the hospitals were established to segregate Indigenous people with tuberculosis (discriminately referred to as “Indian tuberculosis”) as there was a high incidence among the Indigenous population even in youth from residential schools (in part because of overcrowding and poor nutrition). Infected Indigenous people in the far north were transported (some by ship) to hospitals also called sanitoriums in southern communities particularly in the Prairie Provinces, Ontario, and Quebec. Indigenous people were plucked from the schools, their homes, and communities if it was suspected they had TB. There was an amendment to the Indian Act allowing physicians to put Indigenous people in hospitals involuntarily for the treatment of infectious diseases. There are horrendous recordings of mistreatment in the hospitals including experimentation with various forms of treatment for TB, such as with vaccines and surgery (removing parts of their lungs, which necessitated removing ribs, often under local anesthetic). When the incidence of tuberculosis decreased, many of the Indian hospitals were transitioned into segregated general hospitals operated with little regard for traditional healing practices or Indigenous culture. In Sioux Lookout Ontario, for example, there were two hospitals, the Zone (also referred to at the time as the Indian hospital) and the Sioux Lookout General Hospital. Physicians and staff were separate (working at one or the other). Physicians often rotated in from Winnipeg or other centres. Non-indigenous people were rarely if ever admitted to the Zone hospital and vice versa. When Medicare was introduced in 1968 the federal government initiated closure of the majority of Indian hospitals merging care of the Indigenous and non-indigenous population into the same facilities. As an example, in Sioux Lookout the Zone and General hospitals were moved to a new facility called the Sioux Lookout MenoYaWin Health Centre, which is a fully accredited sixty bed acute care facility offering an additional twenty beds for extended care. The Role of Volunteer Organizations in Early Health Care In the eighteenth and early nineteenth centuries Canadians’ health care needs were attended to largely by volunteer organizations, which were also relied upon heavily to raise funds for health care because there was little or no funding provided by the government or any other agency. Some of these groups are discussed below. Many will be familiar because they still function today. The Order of St. John The Order of St. John (later known as St. John’s International and sometimes St. John Ambulance) provides community-based ﬁrst aid, health care, and support services around the world. The organization was introduced to Canada in 1883 by individuals from England with knowledge of ﬁrst aid, disaster relief, and home nursing. The organization and its volunteer responsibilities expanded over the years, providing invaluable assistance and health care to Canadians. Today the organization provides a wide range of health care services at public events and participates in community health initiatives across Canada. They also offer a number of courses (including online) ranging from emergency and standard ﬁrst aid (including pets) to family, children, and youth courses (St. John Ambulance, 2018). The Canadian Red Cross Society The Canadian Red Cross Society was founded in 1896. In the early 1900s, the Red Cross established a form of home care designed to keep families together during times of illness. The Red Cross gradually became involved in other public health initiatives, establishing outpost hospitals, nursing stations, nutrition services, and university courses in public health nursing (Canadian Red Cross, 2008). Until 1998 the Canadian Red Cross Society also supervised the collection of blood from volunteer donors across Canada. The society was stripped of this responsibility following the contaminated blood crisis. Two thousand people who had received blood and blood products contracted HIV; another 30 000 people were infected with hepatitis C. After the 1997 report prepared by Mr. Justice Krever, Final Report: Commission of Inquiry on the Blood System in Canada, a new national blood authority, Canadian Blood Services, was created and assumed. On September 26, 1998, Canadian Blood Services assumed full responsibility for the Canadian blood system outside of Quebec (in Quebec, Héma-Québec), and it continues in that role today (Canadian Blood Services, 2014; Picard, 2014; Wilson, 2007). The organization also offers educational courses including those in cardiopulmonary resuscitation (CPR), ﬁrst aid, and water safety, and provides Canadians with a variety of community support services. Did You Know? Today the Canadian Red Cross remains part of a worldwide humanitarian network providing emergency aid and disaster relief in Canada and abroad. For example, in 2017 the society responded to catastrophic ﬂooding in British Columbia, Ontario, Quebec, and New Brunswick as well as to communities devastated by forest ﬁres (e.g., Fort McMurray, Alberta in 2016, and BC in 2017). Support is based on need. Services range from providing shelter, distributing clothing and food, to overseeing ﬁnancial aid. The Red Cross has online options through which the public can make donations of all kinds. Victorian Order of Nurses The Victorian Order of Nurses (VON) was founded in 1897 and was one of the ﬁrst groups to identify the health care needs of the population, particularly of women and children in remote areas of the country, and to provide services to these groups. For many years VON was the largest national provider of home care in addition to providing a wide range of health and wellness services. In November 2015, ongoing ﬁnancial difﬁculties forced the organization to terminate services in Alberta, Saskatchewan, Manitoba, New Brunswick, Manitoba, Newfoundland and Labrador, and Prince Edward Island. Restructuring has allowed operations to continue in Ontario and Nova Scotia. Thinking it Through Volunteers have played a major role in the development of health care in Canada over the years. Today, in the face of widespread shortages in health care services, both in hospitals and in the community, the health care system increasingly depends on volunteers. 1. What roles do volunteers continue to play in health care? Identify four areas that would beneﬁt from the contributions of volunteers. 2. How do you think social and demographic trends will affect the roles of volunteers and volunteer organizations? Children’s Aid Society The Children’s Aid Society of Toronto was created in 1891 by John Joseph Kelso. He initiated the Act for the Prevention of Cruelty to children and animals along with the Better Protection of Children in 1893, which provided the ﬁrst social safety net for the many abandoned and homeless children in the city. The Children’s Aid Society (CAS) was established with the mandate to legally provide protection for these impoverished children. The CAS was granted legal right to care for abandoned and neglected children, to supervise their care, and transfer guardianship from the parents’ care to the CAS when necessary (Until the Last Child, 2014). However, the initial focus was providing food and shelter to disadvantaged children. Children at risk for harm or abuse and needing protection were removed from the family environment and placed in foster homes or orphanages with little thought given to maintaining the family unit. Originally the Children’s Aid Society acted as board members and assumed duties that paid professionals perform today. Today the provision of a secure and caring environment for the child is still paramount, but keeping families together is also a priority. The CAS oversees many of the adoptions in Canada. The Concept of Public Health Is Introduced At the beginning of the nineteenth century, the prevalence of infectious diseases peaked. In 1834, William Kelly, a British Royal Navy physician, suspected a relationship between sanitation and disease and deduced that water was possibly a major contaminant. Although how disease spread was not clearly understood, many recognized the effectiveness of quarantine practices in limiting the spread. Upper and Lower Canada each established a board of health in 1832 and 1833, respectively. These boards of health enforced quarantine and sanitation laws, imposed restrictions on immigration (to prevent the spread of disease), and stopped the sale of spoiled food. Some health care measures met tremendous public opposition. For example, in the mid-1800s a doctor in Nova Scotia attempted to introduce a smallpox vaccine, which had been discovered and proven successful in England around the turn of the century. Public resistance was strong despite proof that the vaccine protected individuals from the disease. Consequently, the value of smallpox vaccinations was not fully appreciated until the 1900s, and as previously mentioned rarely provided for Indigenous people. In the early 1900s, the provinces began establishing formal organizations to manage public health matters. A bureau of public health was established in Saskatchewan in 1909 and became a government department in 1923. The provinces of Alberta, Manitoba, and Nova Scotia likewise established departments of health in 1918, 1928, and 1931, respectively. These public health units assumed responsibility for public health matters, including activities such as pasteurizing milk, testing cows for tuberculosis, managing TB sanatoriums, and controlling the spread of STIs. Maternal and child health care became a focus of public health initiatives at the beginning of the twentieth century. Both doctors and nurses actively promoted such things as immunization clinics and parenting education. The Role of Nursing in Early Health Care Nursing care has been an essential part of health care in Canada since before Confederation, when the Hôtel-Dieu Hospital in Quebec launched the ﬁrst structured training for North American nurses in the form of a nursing apprenticeship (Canadian Museum of History, 2004). In 1873, the ﬁrst school of nursing was established at Mack’s General and Marine Hospital in St. Catharine’s, Ontario (Mount Saint Vincent University, 2005). Another nursing school opened at Toronto General Hospital in 1881. Over the next 50 years, many hospital-based schools of nursing were established, and in 1919 the University of British Columbia offered the ﬁrst university degree program for nurses. The Canadian National Association of Trained Nurses (CNATN) became Canada’s ﬁrst formal nursing organization in 1908, with a mandate to provide support for nurses graduating from formal programs. In most jurisdictions, graduates of hospital-based programs held a diploma in nursing and were eligible to write provincial/territorial examinations to become Registered Nurses (RN). In the mid-1970s, nursing education was transferred to colleges and universities. Graduates still wrote provincial/territorial examinations and held either a diploma or a degree in nursing (program speciﬁc). In the 1990s, diploma programs for RNs were phased out with entry to practise now at the baccalaureate level, except in Quebec. Now there are transfer degree programs where students may begin in community college and enter into a university-degree program to complete their degrees. Nurse Practitioners (NPs) were ﬁrst introduced in Canada in the 1960s. Today NPs practise in all jurisdictions in a variety of settings (see Chapter 9). Provinces and territories also employ registered practical nurses (RPNs) (Ontario) and licensed practical nurses (LPNs) (all other jurisdictions). Personal support workers (PSWs) also play an important role as members of the health care team. There are numerous specialties that nurses can prepare for (e.g., pediatric nursing or cardiology). It is important to note that for RPNs in Canada, also an acronym for Registered Psychiatric Nurses, educational programs are offered in British Columbia, Alberta, Saskatchewan and Manitoba (more detail in Chapter 9). The introduction of health insurance Concerned about the continued shortage of physicians within their community, in 1914 the residents of the small municipality of Sarnia, Saskatchewan devised a plan, without government approval, to offer a local doctor $1500 (from municipal tax dollars) as an incentive to practise medicine in the community rather than join the army. The scheme proved successful, and over the next several years attracted a number of doctors to the area. In 1916 the provincial government passed the Rural Municipality Act, formally allowing municipalities to collect taxes to raise funds for retaining physicians, and administering and maintaining hospitals. By 1931, 52 municipalities in Saskatchewan had enacted similar plans. Not long afterward, the provinces of Manitoba and Alberta followed suit. In 1919, the ﬁrst federal attempt to introduce a publicly funded health care system formed part of a Liberal election campaign. However, once in power, the Liberals were unsuccessful in their negotiations for joint funding with the provinces and territories and the plan was not carried out. In the aftermath of the Depression in the 1930s, public pressure for a national health program mounted. Canadians realized that a more secure, affordable, and accessible health care system was necessary. First Attempts to Introduce National Health Insurance In 1935, the Conservative government of R.B. Bennett pledged to address social issues such as minimum wage, unemployment, and public health insurance. Bennett’s government proposed the Employment and Social Insurance Act on the advice of the Royal Commission on Industrial Relations. Under the Act, the federal government would gain the right to collect taxes to provide social beneﬁts. However, the Act was declared unconstitutional by the Supreme Court of Canada and the Privy Council of Great Britain on the grounds that it violated provincial and territorial authority. Although employment and social insurance were deemed the responsibility of provincial and territorial governments in 1937, shortly thereafter the federal government began to secure some gains in overseeing social programs. In 1940, under Prime Minister Mackenzie King, the provincial and federal governments agreed to amend the British North America Act to allow the introduction of a national unemployment insurance program. By 1942, this program was fully operational. Two years later, in 1944, the federal government passed another piece of legislation introducing family allowances for each child aged 16 and under (often referred to as “the baby bonus”), paving the way for more social programs, the modiﬁcation of existing ones, and formalized health insurance. Post–World War II: The Political Landscape Major changes in Canada’s political landscape followed World War II. Provinces and territories began to exercise more authority over the social and economic lives of their populations. A shift in thinking, largely due to the devastating effects of the Depression, resulted in the idea that governments were responsible for providing citizens with a reasonable standard of living and acceptable access to basic services, such as health care. Canadians wanted the security and equity that a publicly funded health care system would bring. Canadians, particularly the middle class, had felt the impact of not having access to appropriate health care. The rich could afford proper care; the poor could turn to charities. The expanding middle class was caught in between. At the same time, medical discoveries were advancing treatment, care, and diagnostic capabilities. A shift from home- to hospital- based care, particularly when complex medical procedures were involved, created a perceived need for a more organized approach to health care. Various social movements advanced this agenda, because people believed the involvement of the federal government would result in more stable and equitable funding, which would then support and promote medical discoveries and treatment options. In 1948, the federal government set up a number of grants to fund the development of health care services in partnership with the provinces. In 1952, these grants were supplemented by a national old-age security program for individuals 70 years of age or older. That same year the provinces and territories introduced ﬁnancial aid for people between the ages of 60 and 69, provided on a cost-sharing basis with the federal government. In 1954, legislation permitted the federal government to ﬁnance allowances for adults who were disabled and unable to work. All of these measures contributed to Canadians’ health and well-being. Despite increasing public requests for a nationally funded health care system, the provinces, the territories, and the federal government continued to struggle over how the system would be implemented. Who would be in charge of what, and how much power would the federal government hold over matters under provincial and territorial control? The federal government, looking for a workable solution, ultimately decided to offer funds to the provinces and territories to help pay for health care costs; however, it also set restrictions on how the funds could be spent. Progress Toward Prepaid Hospital Care The National Health Grants Program of 1948 marked the ﬁrst step the federal government took into the provincial and territorial jurisdictions of health care. Through this program the federal government offered the provinces and territories a total of $30 million to improve and modernize hospitals, to provide training for health care providers, and to fund research in the ﬁelds of public health, tuberculosis, and cancer treatments. Welcomed in all jurisdictions, these grants resulted in a hospital building boom that lasted nearly 30 years. The next decade saw little progress in the introduction of comprehensive insurance plans in the provinces and territories. Then, in 1957, the federal government under John Diefenbaker introduced the Hospital Insurance and Diagnostic Services Act. The Act proposed that any province or territory willing to implement a comprehensive hospital insurance plan would receive federal assistance in the form of 50 cents on every dollar spent on the plan, literally cutting in half the province’s or territory’s expenses for insured services—an appealing offer indeed! Five provinces, along with the Northwest Territories and Yukon, bought into the plan immediately. All remaining jurisdictions were on board by 1961. Even with the ﬁnancial aid of the federal government, some provinces and territories were not able to implement comprehensive services, primarily because of population distribution. To rectify this problem, the federal government introduced an equalization payment system through which richer provinces would share revenue with poorer provinces to ensure all could offer equal services. The Hospital Insurance and Diagnostic Services Act stated that all residents of a province or territory were entitled to receive insured health care services upon uniform terms and conditions. The Act provided residents with full care in an acute care hospital for as long as the physician felt necessary. It also included care provided in outpatient clinics, but not in tuberculosis sanitariums, mental institutions, or homes for the aged. Services for some allied health workers (e.g., physiotherapists) and other nonmedical professionals, as well as diagnostic procedures, were covered by provincial and territorial health insurance plans only if the care was provided in a hospital setting and under the direction of a physician. This coverage paved the way for a huge increase in hospital admissions, some more necessary than others. If prepaid health care was available with no out-of-pocket fee in the hospital, why would a patient go elsewhere where he or she would have to pay? As a result, spending for hospital services increased dramatically. Progress Toward Prepaid Medical Care Tommy Douglas, known as the father of medicare (although this remains controversial—Justice Emmett Hall is also sometimes referred to as Canada’s father of Medicare), was the premier of Saskatchewan from 1944 to 1961 (Tommy Douglas Research Institute, n.d.). Douglas long campaigned for a combined comprehensive hospital and medical insurance plan that everyone could afford. He ﬁrmly believed that the implementation of a social health insurance plan was a government responsibility and that private insurance plans, although useful, discriminated against those with lower incomes, disabilities, and serious health issues. In 1939, the Saskatchewan government enacted the Municipal and Medical Hospital Services Act, permitting municipalities to charge either a land tax or a personal tax to ﬁnance hospital and medical services—a precursor to comprehensive hospital insurance in the province. Eight years later, in 1947, Tommy Douglas’s government passed the Hospital Insurance Act, guaranteeing Saskatchewan residents hospital care in exchange for a modest insurance premium payment. In 1960, Douglas was ready to take the next step of providing Saskatchewan citizens with comprehensive, publicly funded medical care, in addition to hospital insurance. His initial attempts to introduce medical care insurance inspired ﬁerce opposition from Saskatchewan doctors, who worried they would be controlled by the province. Douglas fought an election campaign with a platform promising to introduce the health insurance program and was re- elected in 1960. The following year, Douglas left Saskatchewan to lead the New Democratic Party in Ottawa. Under his successor, Premier Woodrow Lloyd, the Saskatchewan Medical Care Insurance Act was passed in 1961 and took effect in July 1962. The day the medicare law came into effect, the doctors in Saskatchewan launched a province-wide doctors’ strike, which lasted 23 days. In early August of 1962, the Saskatchewan government revised the Medical Care Insurance Act in an attempt to repair the relationship with the province’s doctors. One amendment allowed doctors the option of practising outside the medical plan, but within three years most doctors were working within the plan ﬁnding it the easier route to follow. (Billing patients separately and collecting money owed proved expensive and time-consuming and resulted in only a marginal difference in remuneration.) Most other provinces and territories adopted similar plans over the next few years. Today physicians are remunerated in several ways, particularly those working within primary care teams (e.g., capitation-based funding and salaried positions (see Chapter 8)). Thinking it Through The Saskatchewan Medical Care (Insurance) Act, which enforced socialized medicine and imposed fee schedules. It is a funding formula that persists across the country today. This means physicians are paid a calculated amount for each patient assessment, dependent on the complexity of the assessment (fee for service). Other funding mechanisms used today include salaries and paying doctors a set amount per year for each patient. The number of times a doctor sees a patient is irrelevant (see Capitation-Based Funding, Chapter 5). 1. Do you know how your physician is paid? 2. Do you think paying physicians for every service is more cost effective than paying them a lump sum per patient, per year (called capitation-based funding)? Significant events leading up to the canada health act The federal government remained committed to a comprehensive health insurance program. Box 1.3 summarizes the Hall Report, the Medical Care Act, and the Established Programs and Financing (EPF) Act, all of which played a signiﬁcant role leading up the Canada Health Act. Box 1.3 Legislation Leading up to the Canada Health Act. The Hall Report (1960)—Royal Commission on Health Services Investigated the state of health care in Canada and was instrumental in passing the Medical Care Act (1966) Passed in the House of Commons December 8, 1966 Supported the introduction of a national medicare Required the federal government share the cost of health care plans implemented by jurisdictions meeting the Act’s criteria (a funding formula created by Tommy Douglas) Suggested the construction of new medical schools and hospitals Recommended that the number of physicians in Canada be doubled by 1990 Recommended that private health insurance companies in the country be replaced by ten provincial public health insurance plans Recommended the federal government retain strong control over health care ﬁnancing but allow provinces and territories some authority over the implementation of their health care services Implementation of the Medical Care Act (1968) Implemented on July 1, 1968, and accepted by all provinces and territories by 1972 Allowed all jurisdictions to administer the plan as they saw ﬁt as long as they adhered to the criteria of universality, portability, comprehensive coverage, and public administration (mirroring the Canada Health Act) Covered only in-hospital care and physicians’ services Caused the federal government, provinces, and territories to recognize the need for community-based care and restructuring of the funding formula because of soaring costs of physician and hospital care The Established Programs Financing Act (1977) Introduced a new funding formula to allocate money to health care and to postsecondary education Replaced the previous 50/50 cost-sharing formula with a block transfer of both cash and tax points Reduced restrictions on how jurisdictions could spend money, allowing them to fund community-based services Provided more transfer money for an extended health care services program, which covered intermediate care in nursing homes, ambulatory health care, residential care, and some components of home care Thinking it Through With the implementation of the Medical Care Act, health care costs rose dramatically, fuelling the claim that health care in Canada is consumer-generated—meaning that because health care is perceived as being free, many have sought care indiscriminately, going to the doctor for almost any complaint. The emphasis today is on health promotion, wellness, and disease prevention, with individuals being more responsible for their own health (e.g., a healthy lifestyle). 1. Do you think consumers should bear more responsibility for system costs by being more discriminating about when and why they access health care? 2. Do you think Canadians as a whole regard health care as “free,” without recognizing they are paying for it (indirectly or otherwise)? Events Following the Introduction of the EPF Act In the few years following the introduction of the EPF Act, health care spending continued to increase dramatically, resulting in provincial and territorial overspending and necessitating cuts to health care. Hospitals had to make cuts—some staff were let go, some medical services were either delisted or cut altogether, and doctors’ fees were capped. In response, in 1978, outraged doctors began billing patients over and above what the provincial or territorial plan paid (in accordance with the negotiated fee schedule). For example, if the public insurance plan paid $25 for a doctor’s visit, the doctor added an extra amount—say $10—and asked the patient to pay out-of-pocket for that service. This practice was called extra billing and contravened the principles of the Medical Care Act. Opposition to extra billing was swift, with the public claiming that the fees unfairly limited access to health care. Tensions rose between physicians and the public sector. Once again, Justice Emmett Hall was asked to lead a health care services review, with the assistance of Dr. Alice Girard from Quebec. The mandate was to scrutinize issues that had risen since the previous Hall Report, including the legality of extra billing. Hall’s conclusions were released in 1980 in a report called Canada’s National–Provincial Health Program for the 1980s. The report stated that extra billing violated the principles of the Medical Care Act and created a barrier for those who could not afford to pay. Hall recommended an end to extra billing and suggested that, instead, doctors be allowed to operate entirely outside of the Medical Care Act. This allowed patients the choice of avoiding a doctor who was not working within the boundaries of the provincial or territorial insurance plan. Physicians opting out of the public insurance plan would bill patients directly for their services; patients would then have to collect money from their provincial or territorial insurance plan. Alternatively, the doctor could bill the plan for services, the plan would pay the patient, and the patient would pay the doctor with the money received, plus any amount the doctor charged above the plan’s allowances. It was a lengthy and cumbersome process. Hall also advised that national standards be created to uphold the principles and conditions of the Medical Care Act, that the criterion of accessibility be added to the Act, and that an independent National Health Council be established to assess health care in Canada and to suggest policy and legislative changes when needed. The recommendations from the second Hall Report were taken seriously but put on hold until the Parliamentary Task Force on Federal–Provincial Arrangements completed its review the following year. This task force was to review the funding arrangements under the EPF Act and the other subsidies the federal government provided to the provinces and territories. The task force’s recommendations included adjusting equalization payments, introducing federal responsibility for income distribution, and separating health care funding from higher education funding. Together, the Hall Report and the report of the Parliamentary Task Force on Federal–Provincial Arrangements prompted the Canada Health Act, new and comprehensive legislation that replaced both the Hospital Insurance and Diagnostic Services Act and the Medical Care Act. The canada health act (1984) The Canada Health Act became law in 1984 under Prime Minister Pierre Trudeau’s Liberal government. It received royal assent in June 1985 and is still in place today, governing and guiding—and perhaps limiting—our health care delivery system. The Act’s primary goal is to provide equal, prepaid, and accessible health care to eligible Canadians (Box 1.4) and thereby meet the objectives of Canadian health care policy (Box 1.5). Box 1.4 Eligibility for Health Care under the Canada Health Act. To be eligible for health care in Canada, a person must be a lawful resident of a province or territory. The Canada Health Act deﬁnes a resident as “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” (Canada Health Act, 1985, s. 2). Each province or territory determines its own minimum residence requirements. Source: Canada Health Act, R.S.C., c. C-6 (1985). Box 1.5 The Primary Objective of Canadian Health Care Policy. “To protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without ﬁnancial or other barriers.” Source: Health Canada. (2004). What is the Canada Health Act? Retrieved from http://www.hc-sc.gc.ca/hcs-sss/medi-assur/cha- lcs/overview-apercu-eng.php. Criteria and Conditions of the Canada Health Act The Canada Health Act established criteria and conditions for the delivery of health care. To qualify for federal payments, the provinces and territories must adhere to the ﬁve criteria discussed below, and also to two additional conditions (Box 1.6). Box 1.6 The Canada Health Act: Criteria and Conditions. Source: Library of Parliament. (2005). The Canada Health Act: Overview and options. Retrieved from http://www.res.parl.gc.ca/Content/LOP/ResearchPublications/94 4-e.pdf. Public Administration The Canada Health Act stipulates that each provincial and territorial health insurance plan be managed by a public authority on a nonproﬁt basis. That is, the health insurance plan must not be governed by a private enterprise and must not be in the business of making a proﬁt. The public authority answers to the provincial or territorial government regarding its decisions about beneﬁt levels and services and must have all records and accounts publicly audited. To meet the criteria of the Act, health plans must be overseen by the Ministry of Health, the Department of Health, or the equivalent provincial or territorial government department. Services provided under the umbrella of the relevant department are distributed via different vehicles, primarily via regional health authorities or the equivalent. Comprehensive Coverage Provincial and territorial health insurance plans allow eligible persons with a medical need to access prepaid, medically necessary services provided by physicians and hospitals. Select services offered by dental surgeons, when delivered in the hospital setting, are also covered. Services included under the provincial or territorial plan must be equally available to all insured residents of the province or territory; there must be no barriers to access (Case Example 1.1). Case Example 1.1 Alois goes to his doctor to have a wart on his hand removed. The procedure may or may not be covered, depending on what province Alois lives in. For example, it is covered in Newfoundland and Labrador, so, as a resident of that province, Alois would have the procedure covered. In Ontario, Nova Scotia, New Brunswick, Manitoba, Alberta, Saskatchewan, and British Columbia though, wart removal on the hand is not a prepaid service, so if Alois lived there, he would have to pay for the procedure himself (or through supplementary insurance). Each province or territory has the latitude to select which services will be covered under its speciﬁc plan. Coverage may include components of home care or nursing home care, chiropractic care, eye care under speciﬁc conditions, and pharmacare for designated population groups. Comprehensive coverage of these provincially or territorially tailored services must be offered to every eligible resident in the jurisdiction. Universality All eligible residents of a province or territory are entitled on uniform terms and conditions, to all of the insured health services that are provided under the provincial or territorial health insurance plan. The federal government allowed the provinces and territories to decide whether they would charge their residents insurance premiums. Where premiums were charged, however, a citizen’s inability to pay could not prevent his or her access to appropriate medical care. The province or territory would then be able to subsidize premiums for those with low incomes, but could not discriminate on any basis—for example, on the individual’s previous health record, current health status, race, or age. Universality means that no matter how young or old, or rich or poor a person is, or what their health condition is, that person is eligible for the same insured health services as anyone else (Case Example 1.2). The exception would be if Juan could afford to access a private facility for some procedures. Case Example 1.2 Juan requires surgery. He lives in British Columbia, a province that charges health care premiums. However, Juan cannot afford to pay the premiums. Universality requires that the province subsidize his premium payments so that Juan can have his surgery and any other health care he needs. Premiums aside, even if Juan were very rich and required surgery for which there was a long wait list, he would not be able to buy his way to the top of the list. Portability Canadians moving from one province or territory to another are covered for insured health services by their province of origin during any waiting period in the province or territory to which they have moved. Most jurisdictions enforce a three-month wait before public health insurance becomes active. Under the Act, the waiting period cannot exceed 3 months. Individuals moving to Canada may also have to endure a waiting period of up to three months, and therefore are encouraged to have private insurance in place in the interim. Canadians who leave the country will continue to be insured for health services for a prescribed period of time. Every province or territory sets its own time frame (usually six months less a day, or 183 days). Ontario states that a person may be out of the country for a maximum of 212 days in any given year, while Alberta, British Columbia, Manitoba, and New Brunswick state that a person must remain in the province for at least six months to retain coverage. In Nova Scotia, with permission and under certain conditions, a temporary absence of up to one year is allowed. Newfoundland and Labrador offer out-of-province coverage for individuals who remain in the province for only four months of the calendar year—the lowest residency requirement of all jurisdictions, in part due to the number of migrant workers in the province. In addition, every jurisdiction offers coverage for special situations, such as absences for educational or work purposes. Although Canadian residents are covered for necessary care (i.e., urgent or emergency care) while absent from their home province (e.g., for business or a vacation), they are not permitted to seek elective surgeries or other planned care in another province or territory. In some cases, prior approval for coverage may be granted for elective nonemergency surgery (Case Example 1.3). The Web sites of the provincial and territorial ministries of health offer information about the particulars of each jurisdiction’s health care coverage. Case Example 1.3 At 69 years old, Nancy is booked for elective hip replacement surgery in six months in her home province of Nova Scotia. However, she decides to visit her sister in British Columbia and have her hip replaced there because surgical wait times are shorter. To ensure that the Nova Scotia government will cover the cost of Nancy’s surgery in British Columbia, she has to contact the Nova Scotia Department of Health for prior approval. If Nancy has the surgery without requesting approval from the Nova Scotia Department of Health, or if she is denied approval, she will have to pay for the surgery out-of-pocket. However, if Nancy falls down the stairs and breaks her hip while she is visiting her sister, the surgery would be done in British Columbia, and the total cost would be covered by her province of origin without question. Insured services received outside the person’s province of origin will be paid at the host province’s rate, except by Quebec (Case Example 1.4). Case Example 1.4 Jeremy, a 20-year-old resident of Ontario, is visiting friends in Saskatchewan. While there he develops a severe and persistent sore throat and pays a visit to a local doctor. Even if the cost of a visit to the family doctor is $20 in Saskatchewan but is only $15 in his home province of Ontario, the Ontario health plan will pay the full $20 required by the doctor in Saskatchewan. Now consider the situation if Jeremy is from Quebec. If the fee for the same doctor’s visit is $15 in Quebec, the Quebec health plan will pay only $15 to the doctor in Saskatchewan, and Jeremy will have to pay $5. Quebec does not honour the host province’s or territory’s fee schedule if it is higher than its own. Accessibility The criterion of accessibility was added to the Canada Health Act in an attempt to ensure that eligible individuals in a province or territory have reasonable access to all insured health services on uniform terms and conditions. Reasonable access means access to services when and where they are available, and as they are available. A service may not be available to a person because of where he or she lives—for example, in a more remote community (Case Example 1.5). Or a service may be unavailable because of a shortage of beds or lack of health care providers to supply the service (Case Example 1.6). Individuals needing a service that is not available must be granted access to that service in the closest location it is offered—whether in another town or city, in another province, or in the United States. Case Example 1.5 Monique is a 40-year-old woman living in Pickle Lake, Ontario. She has just been diagnosed with breast cancer. Her community does not have access to radiation therapy, but this therapy is available in Thunder Bay, Ontario. In accordance with the accessibility criterion, Monique would be sent to Thunder Bay for her treatments. If radiation therapy was not available in Thunder Bay—or if the wait time was excessive—Monique would be sent to Winnipeg, Manitoba. Case Example 1.6 Pang went into labour at 28 weeks’ gestation. Delivery was imminent, and it was concluded that no facilities in her home province of British Columbia or close by could provide the highly specialized care required for the premature baby (reasons for such service unavailability could include no bed being available or a shortage of nursing staff). Pang was transferred by air ambulance to a hospital in Washington. The baby stayed in hospital for three weeks until he was stable enough to be sent back to British Columbia. The BC Medical Care Plan covered all medical expenses. Accessibility applies to wait times as well. Some jurisdictions have established maximum wait times for certain procedures. If a person has to wait for a procedure (e.g., a hip replacement) beyond that set time limit, the province or territory will send the person somewhere else for the procedure (see Case Example 1.3). Note, however, that a province or territory would pay for a patient to receive an available service only at the closest alternative location, not a location farther aﬁeld or one that the patient prefers. The interpretation of reasonable access is controversial. A person living in Churchill, Manitoba, will not have the same access to health care as a person living in Halifax, Toronto, or Vancouver. Today service availability varies even between rural and urban settings. For the purposes of the Canada Health Act, accessibility has been interpreted as access to services where and when available. It does not, in the true sense of the word, guarantee “equality” of services across Canada. The following two conditions were imposed upon provinces in the Canada Health Act: Information. Each province or territory must provide the federal government with information about the insured health care services and extended health care services for the purposes identiﬁed in the Canada Health Act. Recognition. The provincial and territorial governments must publicly recognize the federal ﬁnancial contributions to both insured and extended health care services. Interpreting the Canada Health Act “Medically necessary” is a subjective term that has been hotly debated within the context of the Canada Health Act (also see Chapter 8). Typically, a physician or other health care provider eligible to bill the provincial or territorial plan makes a clinical judgement to provide the patient with speciﬁc medically necessary services, which usually include assessment, diagnostic tests, and treatment. Note, however, that some jurisdictions may not cover all diagnostic tests and treatments. Since the Canada Health Act does not detail which services should be insured, the range of insured services varies among provinces and territories. Medical services (e.g., caesarean section) must not be provided simply for the convenience of the patient or physician. And when more than one treatment is available, a physician must consider cost effectiveness. For example, when faced with two treatment options that have similar outcomes, a physician must recommend the less expensive option. What one doctor considers medically necessary another doctor may not. Consider breast reduction: a surgeon in Manitoba might determine that this surgery is medically necessary for a particular patient with large breasts because of the backaches and muscle strains she suffers. Another surgeon may not think breast reduction is medically necessary for this patient, meaning that the patient would have to pay for the surgery since it would then be considered a cosmetic procedure. Thinking it Through The term medically necessary appears in the Canada Health Act to identify procedures and services that are covered by provincial and territorial health insurance. 1. Do you think that the term is too subjective? 2. Are there health services in your province or territory that you feel should be covered but are not? Physicians, through their governing body, and government ofﬁcials—usually from the Ministry or Department of Health—select which services are medically necessary and are, therefore, insured. At designated intervals, the provinces and territories review their lists of insured services, sometimes adding services, sometimes removing them. For example, a few years ago many jurisdictions removed elective newborn circumcision from the list of insured services because evidence showed no medical reason for this procedure and found other reasons (e.g., a belief that a circumcised penis is cleaner, or that the baby should resemble his father), to be invalid. However, circumcision is still insured when a valid medical reason exists for doing it. Also addressed in the Canada Health Act are extra billing and user charges—a fee imposed for an insured health service that the provincial or territorial health care insurance plan does not cover. Under the Act, extra billing and user charges are not

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