Part 3 - Practice: Improving Health

Chapter 12 The Organization of Health Services in Canada

Some specific types of services

Occupational health services

Occupational health services in Canada are divided into two distinct sections. The first aims to protect workers and prevent work-related injury and ill health. It is generally known as health and safety at work, although the names of the legislation and authorities governing it vary between provinces and territories. The second section aims to rehabilitate people who have been injured at work or who suffer from occupational illness, and to compensate workers whose health has been damaged by work. This is generally administered by a workers’ compensation board—again, names differ. Some large corporations in Canada maintain their own occupational health services, but must still respect occupational health legislation.

Health and safety at work

The provinces and territories are responsible for providing occupational health services. They do so within the framework of the Canadian Labour Code. Employees of most industries are covered by provincial legislation, and the types of industry covered vary slightly by province or territory. Certain industries that cross provincial and national boundaries are covered under federal legislation. Some employees, such as those working in domestic employment (for instance, domestic workers in private households), are generally not covered. The authorities responsible for providing services also vary by province or territory.

Health and safety at work…
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Health and safety at work

For more about health and safety at work in Canada, visit the Canadian Centre for Occupational Health and Safety website at: http://www.ccohs.ca/ and the Human Resources and Skills Development website at : http://www.hrsdc.gc.ca/eng/labour/health_safety/index.shtml

In spite of provincial differences in organization, all Canadian workers have certain rights and duties under the Labour Code:

Rights of workers include

Right to know. That is the right to know about work-related hazards. This includes the training and supervision necessary to protect the worker’s health.

Right to participate in health and safety. Employers with 300 or more employees are required to establish a health and safety committee, which includes representation from workers and from management. Its objective is to develop a health and safety policy. Other employers (those with fewer than 300 employees) may choose to do so. Workers have the right to participate in the committee and policy deliberations. They may also participate through the internal complaint resolution process covered under the Canadian Labour Code.

Right to refuse. Employees can refuse to work if the work is dangerous to themselves or others and if the danger is not a normal condition of employment.

The duties of workers include; using the safety equipment provided, respecting health and safety procedures, instructions and policies that relate to the hazard or to the use of safety equipment, and reporting potential workplace hazards as well as injuries and hazardous events.

The duties of employers are; to provide a safe workplace, to respect safety standards, and to ensure that workers receive the information and training they need to protect their health.

Workers’ compensation

Organized workers’ compensation in Canada began with the 1913 Meredith Report, and is administered by Workers’ Compensation Boards. One of the major goals of most workers’ compensation boards is to get workers with occupational illness back to work. To do so, compensation may cover rehabilitation costs, including, for instance, outpatient physiotherapy services. As such, workers’ compensation can provide a broader range of services than does the provincial health care plan. The ill worker remains under the care of his or her usual treating physician who, on request of the patient, must provide a letter to support the patient’s claim for compensation and will continue follow-up of the patient’s condition. Apart from medical care, return to work may require changes in the patient’s work-station, entailing work with, for instance, occupational therapists or occupational hygienists and the patient’s employer.

Five basic principles of workers’ compensation.

The basic principles of workers’ compensation were set out in the 1913 Meredith Report and survive today. They are:

1. No-fault compensation. Workplace injuries are compensated regardless of fault. Neither worker nor the employer can sue, nor are they expected to admit responsibility, except in a case of gross negligence.

2. Collective liability. The total cost of the compensation system is shared by all employers in proportion to the costs of claims for each occupational sector. For instance, the forestry sector pays higher premiums than the office work sector. All employers contribute to a common fund and financial liability becomes their collective responsibility. However, employers’ contributions may be adjusted to reflect the cost of successful claims of their workers.

3. Security of payment. Injured workers are assured of prompt compensation and future benefits.

4. Exclusive jurisdiction. All compensation claims are directed solely to the compensation board. The board is the decision-maker and final authority for all claims. The board has the authority to judge each case on its individual merits.

5. Independent board. The governing board is both autonomous and non-political. The board is financially independent of government or any special interest group. The administration of the system is focused on the needs of its employer and worker clients, providing service with efficiency and impartiality.

Workers’ compensatio…
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Workers’ compensation

Information about workers’ compensation, including the Meredith Report and workers’ compensation boards, is available at the Association of Workers’ Compensation Boards of Canada website at: http://www.awcbc.org/en/index.asp

Public health services in Canada

Development of the public health system

Public health activities remained fairly uncoordinated until relatively recently. As cities grew, water and sanitation services developed with engineering advances, and were coordinated by municipalities. Quarantine and isolation became important in the early and mid-19th century, when waves of immigrants brought cholera and typhus with them to Canada. In the early 20th century some towns began to chlorinate water, rural towns began to pasteurize milk, and Ontario began to immunize against smallpox and diphtheria.

Grosse Île Grosse …
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Grosse Île

Grosse Île in Québec was the main quarantine station in Canada in the mid-nineteenth century. It is now a national park. Information about it and its history can be found at the Parks Canada website: http://www.pc.gc.ca/eng/lhn-nhs/qc/grosseile/index.aspx

In 1974, the Lalonde Report emphasized the need to look beyond the care of the sick in order to improve the health of the population, so that the health care system should include action on environment, lifestyle and health care organization, as well as biology. It was the first Canadian report on the health system to mention the importance of health promotion and prevention in maintaining population health. In 1986, with the first international conference of health promotion being held in Ottawa, the then Minister for Health and Welfare, Jake Epp, presented "Achieving Health for All: A Framework for Health Promotion." This report reflected the Ottawa Charter for Health Promotion (which had been ratified at the same conference); the Framework set out the direction for health promotion in Canada. It said that Canada should attempt to reduce inequities, to increase the prevention effort, and enhance people’s capacity to cope. It suggested that this could be achieved by fostering public participation, strengthening community health services, and coordinating public health policy.

Until the turn of the millennium, public health continued to take a back seat to personal health services and received about 3% of overall health funding. Although some provinces, such as British Columbia and Quebec, had developed coherent structured public health systems, including provincial organizations providing public health expertise (BC-CDC in British Columbia and the INSPQ in Quebec), in most provinces public health provision remained poorly coordinated.

In 2000, an E. coli outbreak killed seven people in Walkerton, Ontario, and affected thousands of others. Then, in 2001, around 6,000 people in North Battleford, Saskatchewan, contracted cryptosporidiosis because of problems with the water supply. In 2002 and 2003, SARS, a previously unknown disease, reached near pandemic levels causing over 8,000 cases in 16 countries. Forty-four Canadians, mostly in Toronto, died. Meanwhile, experts in public health were warning of an impending influenza pandemic. During the same period, the 9/11 attacks in New York and several terrorist attacks in Europe and Asia occurred, and extreme weather conditions were causing death and injury around the world. These man-made and natural disasters increased awareness of the need for public health services disaster planning around the world.

The events in Canada demonstrated the weakness of the public health infrastructure. In response, the 2006 Public Health Agency of Canada Act came into force establishing a Chief Public Health Officer for Canada who would

Advocate for effective disease prevention and health promotion programmes and activities

Provide science-based health policy analysis and advice to the federal minister for health

Provide leadership in promoting special health initiatives

Improve the quality of public health practice.

The Act also created the Public Health Agency of Canada, whose mission is to promote and protect the health of Canadians through leadership, partnership, innovation, and action in public health. The agency would

Concentrate and focus federal resources

Enhance collaboration between different levels of government

Allow faster, flexible response to emergencies

Improve and focus communication

Allow for longer-range plans than the usual annual planning cycle of governments

Achieve greater success in attracting and retaining public health professionals.

In keeping with its origins, the agency’s immediate priorities were emergency preparedness, immunization, and chronic disease prevention.

Public Health. The Chi…
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Public Health.

The Chief Public Health Officer of Canada uses Last’s35 definition of Public Health: "The organized efforts of society to keep people healthy and prevent injury, illness and premature death." It is a combination of programmes, services, and policies that protect and promote the health of Canadians.36

Public Health Responsibilities in Canada

According to the Public Health Agency of Canada, public healthpublic healthin Canada, that branch of the health system that deals with health protection, health surveillance, disease and injury prevention, population health assessment, health promotion and emergency preparedness and response. Otherwise, it is defined as the science and art of preventing disease and promoting health through the organised efforts of society. There is debate about the definition of public health. Terms such as community health or population health are often used synonymously. is concerned with six essential activities:36

  1. Health protection: This includes ensuring that water, air and food are safe, maintaining the regulatory framework for the control of infectious disease and protection from environmental threats, as well as advising on food and drug safety regulations.
  1. Health surveillance: The ongoing, systematic use of routinely collected health data for the purpose of tracking and forecasting health events or health determinants. It includes
    • The collection and storage of relevant data
    • The integration, analysis, and interpretation of these data
    • The production of tracking and forecasting products with the interpreted data
    • Publication and dissemination of those products
    • Provision of expertise to those developing or contributing to surveillance systems, including risk surveillance.

The information produced by surveillance is used in planning services and prevention programmes.

  1. Disease and injury prevention: The investigation, contact tracing, and development of preventive and control measures to reduce the risk of infectious disease emergence and outbreaks as well as the promotion of safe, healthy lifestyles to reduce preventable illness and injuries.
  1. Population health assessment: Understanding the health of communities or specific populations, as well as the factors that underlie good health or pose potential risks, to produce better policies and services.
  1. Health promotion: Preventing disease, encouraging safe behaviours, and improving health through public policy, community-based interventions, active public participation, and advocacy or action on environmental and socio-economic determinants of health.
  1. Emergency preparedness and response: Planning for natural disasters (e.g., floods, earthquakes, fires, dangerous infectious disease) and man-made disasters (e.g., those involving explosives, chemicals, radioactive substances, or biological threats and social disruption).

As with general health care services, responsibility for public health is shared between the federal, provincial, and territorial governments. Provinces and territories are responsible for providing services to their population; however, the organisation and the services offered vary across the country.

Provincial public health …
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Provincial public health services

To find out how public health services are delivered in each of the provinces and territories, visit the National Collaborating Centre for Healthy Public Policy website: http://www.ncchpp.ca/en/structuralprofile.aspx

Coordination of world health

The World Health Organization is the directing and coordinating authority for health within the United Nations system. It was created in 1948 and is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries, and monitoring and assessing health trends. It currently focuses on six approaches to improving health:

1. Promote development

2. Foster health security

3. Strengthen health systems

4. Harness research, information and evidence

5. Enhance partnerships

6. Improve system performance.

Recent successes were the agreement on a code of practice for international recruitment of health personnel, and a framework for action on interprofessional education. It is, however, confronting several other major global problems, including food safety and fraudulent medical products. The WHO must also monitor the health-related Millennium Development Goals, and develop strategies to reduce the harmful effects of alcohol, and to address the rise of chronic non-communicable diseases, including the issue of marketing food and beverages to children, which contributes to obesity and poor dental health.37

Responsibility for Promoting Health

A brief look at the list of health determinants confirms that no one authority can be responsible for the health of a population. Health promoters believe that it should be the responsibility of all members of a population or community, and a core responsibility for all government.38,39 Although those working within the health services have a particular responsibility to advocate for health, expertise in public and population health can be found in a variety of different academic disciplines, professions, and organizations. Experts in public health come from a variety of different backgrounds and may use different names to describe their expertise.

Community mobilization is the strategy of choice for sustainable health promotion. In this approach, community members are involved in defining the problems and in proposing solutions. Unlike classic top-down health education, where health professionals study and prioritize problems and then develop solutions, community mobilization involves community members in the process of defining and transforming problems. It is a long-term process that empowers communities, allowing them to take over health-promoting action.

Who does public health? …
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Who does public health?

Public health teams comprise a wide range of professionals with interests in diverse aspects of health. Many have a basic training in the clinical sciences, such as physicians, nurses, psychologists, social workers, dieticians, kinesiologists etc. They work at all levels in the health system from the provincial and federal government to the local and regional health authorities and some work in community health service centres. Those who work in public health departments manage and deliver public health programmes, which generally include transmissible and environmental disease protection, well baby, vaccination and sexual health programmes. Statisticians and epidemiologists carry out health surveillance.

The Royal College of Physicians and Surgeons designates public health and preventive medicine as the branch of medicine concerned with the health of populations. Through interdisciplinary and intersectoral partnerships, the public health and preventive medicine specialist measures the health needs of populations and develops strategies for improving health and well-being through health promotion, disease prevention, and health protection.40

Public health law

Much of public health law was drawn up in the 19th century when the discipline of public health was gaining recognition. Quebec, having invested in public health for some time, is the first province to have developed a sophisticated system that was consolidated by its adoption of its Public Health Law in 2001. The most notable recent event in Canada was the creation of the Public Health Agency of Canada. Public health law is still evolving; it has the following characteristics:

Recognition of the special responsibility of government in public health

The focus on population health

The regulation of the relationships between the state and populations, and between the state and individuals who may pose a risk to the public’s health

Government provision of public health services

The government power to coerce individuals and businesses in order to protect the public’s health.

Public health law respects the following principles:

Duty of government to protect the health and well being of the population

Power to set standards of health and safety and ensure compliance

Restraint in the exercise of power; should act only on the basis of clear criteria where necessary, procedural due process.

Public health law assigns the government the legal power and duty to ensure conditions for people to be healthy (e.g., to identify, prevent, and ameliorate risks to health in the population). It places constraints on autonomy, privacy, liberty, propriety, or other legally protected interests of individuals for the protection or promotion of community health, but it also places limitations on the power of the state to constrain these interests.41


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