The Organization of Health Services in Canada

“Every system is perfectly designed to achieve precisely the results it achieves.”
(Don Berwick, Institute for Healthcare Improvement, Boston)

Elements of the Health Care System

Health care systems are complex organisations comprising regulatory, funding, and service provision bodies that provide access to health care in accordance with societal goals and values. The metaphor of a house (Figure 12.1) can be useful in describing health care systems. The roof corresponds to the societal goals and values that protect service provision, operating via legislation and regulations that control the relationships among providers (the rooms of the house), funding agencies (the power source) and citizens (the people who visit). Regulations also control who can provide care (back door) and who can access it (main door). Note that the model can be applied to the country as a whole or to smaller regions. It can also be applied to specific programmes, such as cancer or HIV/AIDS care.

Societal goals and values

In common with most other developed countries, Canada treats health care as a resource for all people. Unlike a commodity that can be bought and sold on the open market, a defining national value holds that access to health care should be based on need, not ability to pay.² This required the involvement of government in establishing publicly organized health care systems, and several historical influences led Canadians to expect government participation in organizing health services. These influences included:

• Migration to towns, which broke many of the informal social networks that provided health and social care for those in need 
• The involvement of government in providing relief during the Great Depression of the 1930s raised expectations for publicly organized health and welfare services
• Two World Wars left many people with new or exacerbated health and social problems, leading them to ask what their country should do in return.

“Access to health care based on need rather than ability to pay was the founding principle of the Canadian health-care system.”² Meanwhile, increasing knowledge in medicine led to more effective health care technology. Governments, noting that healthy people are more economically productive than unhealthy ones, began to see the advantage of funding health care services. The Nerd’s corner box describes the gradual evolution of legislation in response to societal pressures. These changes occurred within a broader global context that was guided by the World Health Organization.

Coordination of world health programs

The World Health Organization (WHO) directs and coordinates health programs within the United Nations system. The WHO was created in 1948 and beyond its familiar role in coordinating the response to communicable disease outbreaks and pandemics, it is engaged in much more. It provides leadership on global health matters such as climate change, addressing gaps in health human resources, and tackling poverty. It collects information to monitor health trends and sets norms and standards; it shapes the health research agenda, articulates evidence-based policy options, and provides technical support to countries. It currently focuses on six approaches to improving health:

1. Promoting development
2. Fostering health security
3. Strengthening health systems
4. Harnessing research, information, and evidence
5. Enhancing partnerships
6. Improving system performance.

These actions contribute to the United Nations Sustainable Development Goals.

The Canada Health Act

As set out in the Constitution Act of 1867, the provision of health care fell under provincial jurisdiction and provinces administered it in different ways. So, for historical reasons, in place of a true national health care system, we have “a decentralized collection of provincial and territorial insurance plans, covering a narrow bucket of services, which are free at the point of care.”² The Nerd’s corner box above shows the gradual evolution of legislation in response to societal pressures, and fuller details were given by Naylor et al.⁵

The Canada Health Act of 1984 augmented the 1867 Constitution Act. The Canada Health Act aims “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.” The Act applies to all services deemed medically necessary for the purpose of maintaining health, preventing disease, diagnosing and treating injuries, illness and disability, and includes accommodations and meals, physician and nursing services, drugs, and all medical and surgical equipment and supplies.

To ensure standards, the Canada Health Act stipulated that the federal government would provide funding to the provinces and territories on condition that they comply with the principles of the Act. This enabled the federal government to ensure some measure of consistency across provincial health systems. The principles of the Act include:

• Public Administration: The provincial or territorial health insurance plan must be administered and operated on a non-profit basis by a public authority accountable to the provincial or territorial government.
• Comprehensiveness: The plan must insure all medically necessary services provided by hospitals, dentists working within a hospital setting, and medical practitioners.
• Universality: The plan must entitle all insured persons to health insurance coverage on uniform terms and conditions.
• Accessibility: The plan must provide all insured persons reasonable access to medically necessary hospital and physician services without financial or other barriers.
• Portability: The plan must cover emergency services for all insured persons when they are visiting another province or territory within Canada. When they move to another province or territory, all insured persons should be able to transfer their insurance to that province or territory.

The Act specifically prohibits EXTRA-BILLING (see Glossary) and USER FEES for insured services, which are defined as

• Hospital services medically necessary for the purpose of maintaining health, preventing disease, or diagnosing or treating injury, illness or disability, and include accommodation and meals, physician and nursing services, drugs, and all medical and surgical equipment and supplies. However, the Act does not define which services or drugs are “medically necessary”
• Any medically required services rendered by medical practitioners
• Any required medical, surgical or dental procedures that can be properly carried out only in a hospital.

The Canada Health Act still forms the basis of our health care system; there have been changes in the way funds are allocated to provinces and territories, but the principles still hold. The cost sharing agreement between the federal and provincial governments, commonly known as Medicare, has formed a bone of contention for 60 years (see the Nerd’s Corner box above). Continuing issues include the federal contribution, currently around 22%, and the leeway for provinces to decide how to spend this. Funding agreements between the federal and provincial governments have changed over time, sometimes substantially, and with this federal government’s influence over provincial health policies.

Governmental Responsibilities

Health care in Canada is a shared responsibility: we have not one, but 14 health care systems—a different one in each province and territory and another at the federal level. The federal government sets standards and principles, and assists in financing provincial and territorial health care services. The provinces and territories are responsible for the administration and delivery of services for most of the population. The federal government is responsible for providing services for First Nations, Inuit and Métis communities, for members of the RCMP, members and veterans of the Canadian Forces, prisoners in federal penitentiaries, and refugee claimants. The federal government also has a role in coordinating the promotion and protection of the public’s health; it contributes to disease surveillance and prevention, it supports health promotion through the Public Health Agency of Canada, and it regulates drugs, medical devices, food, and consumer safety through Health Canada.

Provincial and territorial governments work within the parameters of the Canada Health Act to provide health care services according to needs in the population. The provinces plan, fund, and evaluate hospital care, physician care, allied health care, prescription drug care in hospitals, and public health; they also negotiate fees with health professionals. Most provinces discharge their health care obligations through regional boards. This decentralizes decision-making and enhances responsiveness to community needs.

In addition to their responsibilities under the Canada Health Act, most provinces and territories run special programs for low-income residents and seniors, covering out-of-hospital drug benefits, ambulance costs, and some level of hearing, vision and dental care. Some provinces and territories fund community health clinics that provide a range of professional services in the community. Some fund extramural programmes, which provide care in patients’ homes, particularly palliative care, post-operative care, home oxygen, long term care assessment, rehabilitation, etc.

Regulating care providers

Governments ensure that care providers meet certain standards in various ways, including:

• Setting the standards for publicly funded institutions that deliver care. Some require regular accreditation assessments, and standards generally require professionals to audit their practice regularly
• Regulating health professionals (the Nerd’s Corner box below gives examples of regulated professions). A regulated professional’s practice 1) operates under provincial or federal legislation, and 2) is governed by a professional corporation or regulatory authority, such as a College of Physicians or an Order of Nurses. Given that many of these regulatory bodies are provincial, variation exists between provinces and territories.

Unregulated practitioners also exist. These describe themselves as formal providers of health care, but they are not members of a professional corporation, nor are they covered by legislation. They may practice without proof of fitness to do so and are not subject to a formal code of ethics.

Sources of Finance

There are two main approaches to funding a publicly financed health care system. The first, a social insurance model, uses compulsory contributions to a social insurance fund. Governments can direct how the premiums are levied and in what amount. Premiums can be linked to a person’s income, often deducted from their pay cheque. In some countries, citizens can choose from a number of insurance providers; in others, the choice is limited to a single national not-for-profit insurer. The social insurance model is used in Japan, Germany, France, and some other European countries.

In the second approach, used in Canada, general taxes fund health care. However, in Canada, only hospital and physician services are universally funded. Other services are funded through a variety of sources, such as social insurance (often used for drug insurance), social security, private insurance, or out-of-pocket fees. Meanwhile, provincial workers’ compensation and health and safety at work programmes are funded by a form of social insurance in which employers pay premiums that are graded according to the inherent risk of the industry and the past safety record of the employer (see Occupational Health Services).

Overall expenditures have been rising in Canada, reaching $264.4 billion in 2019, or just over $7,000 per person. Of this, nearly 60% goes to hospital costs, pharmaceuticals and physician salaries.⁶ 

Public versus private financing of health care

A continuing policy debate in health care financing concerns whether or not people should be allowed to pay out of pocket or to buy private insurance for services that are also publicly funded, for example to reduce waiting time for an operation (see box: The Chaouilli affair). Traditionally, about 25% of health care spending in Canada is out-of-pocket or from private insurance. Proponents of private financing argue that this takes pressure off the public system. However, human resources connect the two systems. The number of qualified professionals is limited, so when professionals work in the private system (part- or full-time), their availability to the public system is reduced. Private care tends to make access more difficult for low-income patients, whose need is often the greatest. A counter-argument is that co-payments for those who can afford them may discourage demand for minor complaints, freeing up resources to treat patients with more serious problems. Note, however, that private insurers generally avoid insuring people with, or at risk of, serious and chronic conditions requiring complex and expensive care. As a result, public funds would continue to be used for the most expensive care, so the reduction in costs to the public system may be small, at least for some care categories. And in addition, human resources would be diverted away from the more complex cases. Finally, private insurers tend to levy large administration costs. For example, in Canada where health care coverage is mainly public, administration costs are 17% of health spending, whereas in the U.S., where coverage is mainly private, the figure is 30% of spending.⁷ A compromise may be to follow the Ontario model of funding private clinics (such as the Shouldice clinic for hernia repair in Toronto) using public money.

Another hot topic concerns whether hospitals should be private, for-profit. Currently, almost all Canadian hospitals are private not-for-profit, operated by regional health authorities.⁸ As such they are viewed as public institutions, although technically they are not. Studies have shown an increased mortality in for-profit hospitals, resulting in fears that attending to the ‘bottom-line’ will harm patient care.⁹ There are also fears that for-profit hospitals will open the door to the free market and erode the principles of the Canadian health care.⁸

Controlling costs

We face a major challenge in controlling the steady rise in health care costs in Canada, portrayed in Figure 12.2. Although population aging has contributed to the increase, the main drivers are the increased use of health care, technological advances, pharmaceutical development and limited incentives to control costs. Of the overall cost of health services, physician costs (at 15% of the total) have risen due to the increased numbers of physicians, while the proportion of overall spending that goes to hospitals (currently 26.6%) has declined steadily since the 1970s.⁶ Health care utilization can change as a result of supply and demand. Both have increased faster in in high- than in low-income countries for a number of reasons. On the supply side, governments in high income countries have greater financial capacity with which to pay for services, and technical innovations create a wider range of services. On the demand side, health messages create a more informed population and encourage them to consult health professionals. In particular, elderly Canadians are making more use of family physician services.^{10, 11} Moreover, marketing of drugs and technology to physicians and directly to consumers increases demand for newer, therefore trade-marked and therefore more expensive options. The net effect is that health care costs are rising faster than the national wealth as measured by the gross domestic product (the red line in Fig. 12.2).

New and more effective treatments are likely to be used more frequently. Because these also tend to be more expensive, costs to the system tend to rise. Costs can also increase when a new technology, developed for a specific application, is used more broadly. For instance, the CT scan was originally developed for brain imaging, but has since become indispensable for imaging many other parts of the body. In the same way, drugs that are approved for limited indications are sometimes marketed ‘off-label’ for a much broader range of indications.

Finally, health care forms a large sector of the economy, and employs a substantial proportion of the working population in Canada, second only to the retail trade.¹³ These individuals, as well as others in  their households, have an interest in maintaining current levels of spending on health and social services in order to maintain their income. In addition, companies that research, develop and produce technologies and pharmaceuticals provide employment, generate income for shareholders, and often produce exportable goods. These companies have a degree of political power as well as a vested interest in providing health care and equipment. In this context, political will tends to maintain or increase health care spending instead of decreasing it.

Economists argue that there are only two ways to reduce health care costs: either reduce the use of services (i.e., reduce demand or offer) or improve their efficiency (reduce their unit cost). Table 12.1 outlines alternative approaches to cost reduction in health services, showing possible side-effects of each approach.

Table 12.1: Approaches to reducing health care costs^{17, 18}

Delivering Care Services

There are two basic ways of delivering publicly funded care. In one, the government itself organizes the delivery of services. This happens in the UK, Cuba, and some Scandinavian countries where health care workers, including physicians, are public employees. Hospital and clinic buildings are owned by the state and services are managed publicly.

The other approach, for instance in Canada, is that service providers can be public or private, but are financed by a public insurance system, so we distinguish between the funding source and the delivery approach (see the Here Be Dragons box). Delivery may be publicly administered, or private services that are for-profit or not-for-profit (including charitable and religious organizations). The private delivery sector includes hospital, long term care and community services funded by provinces. Most physicians, working in hospitals or elsewhere, contract with the provincial insurance plan to deliver services as private service providers. For patients with private insurance or who can afford to pay out-of-pocket, and who want services not covered by the provincial insurance plan, there is a wide range of professionals working outside of hospitals providing services such as physiotherapy, occupational therapy, optometry, podiatry, or psychology.

Remuneration of providers

There are various ways of paying health care providers for their services. Chapter 7 introduced Donabedian’s structure, process and outcome way of thinking about the quality of care, and this can be extended to the design of payment systems.^{23, 24} The costs of service delivery (and hence payments) can reflect the structure of the institution (number of hospital beds, staff numbers, etc.). Alternatively, payments can be based on the services provided: the process of care, in Donabedian’s term. A third option is that quality can be judged, and payments allocated, according to the outcomes of care (the success rates). In Canada, most physicians are paid by a fee per item of service, i.e. a process of care payment, while block funding is used for most institutions, based on a combination of structure and process (see Table 12.2).

Table 12.2: Approaches to paying health care providers

There is no perfect method of remuneration for service. Research on the effects of remuneration methods on quality of care and health outcomes is lacking, and definitive conclusions about which method of payment might be best are not available.

Ensuring access to care

High quality primary care is the cornerstone of equitable, efficient, and effective health care.^{29, 30} In addition to physician services, the notion of primary care includes nurse practitioner services, well-baby and other preventive care, home care, elderly care, social work, and crisis intervention. In some countries, primary care physicians act as gatekeepers to higher levels of care, directing patients to the most appropriate services and following up after consultation, thus reducing inappropriate use of other, more expensive levels of services. Well-managed primary care services ensure preventive care and timely follow-up for all their patients and can act as a resource in advocating for community health. Several models of primary care services have been tested in Canada. Their common objective is to integrate services, bringing physicians out of their traditional, unidisciplinary practice and into collaboration with other types of professionals as pivotal members of multidisciplinary teams that provide the services patients need.

The concept of access to health care services includes:^{31, 32}

• Availability: the relation between the demand for services and their supply;
• Accessibility: the geographical relationship between the location of services and the people who need them;
• Accommodation: the relationship between the manner in which the services are provided and the constraints of people who need them. Constraints can be physical, social, time or cultural;
• Affordability: the relationship between the cost of services and the ability of users and potential users to pay;
• Acceptability: the extent to which people who need services are comfortable using them.

Availability

While many forms of health care are available in Canada, publicly financed health care systems generally only provide allopathic medical care (see ALLOPATHY in the Glossary). Allopathic medicine is also highly regulated to ensure the safety of users; other forms of care are, in general, less regulated. Having a regular care provider, waiting times for appointments, and unmet need are the usual measures of health care availability. Uptake of preventive care may also indicate its availability.

Accessibility

Rural areas tend to lack primary care physicians and other health professionals. In spite of financial incentives to practise in rural areas, physicians cite social, family, and professional reasons for preferring urban practices. Some Canadian medical schools provide training in rural areas, hoping that the experience will induce physicians to remain in them. For practical and economic reasons, rural areas will likely continue to have less access than urban areas to specialized care. Other ways of providing care, such as joint or shared care and telemedicine, need to be developed.

Accommodation

Many people are constrained by work or family responsibilities, so are unable to attend clinics during the usual clinic hours. Similarly, people without private transport may be excluded from clinics not served by public transport. Services must take into account the particular problems of vulnerable populations who often are most in need of care and least able to access it: wheelchair access ramps and adequate lighting are requirements, while many people with substance abuse problems need mobile outreach services.

According to the Public Health Agency of Canada, approximately 60% of adult Canadians have limited reading skills that prevent them understanding health information. Few admit to having such difficulty, but they do not understand written materials on their condition, its management and the medications they need. It is hardly surprising that these people are less able to participate in managing their illness and suffer the outcomes of poor compliance. As low literacy is associated with poor education and poverty, people with low literacy often experience poor health for these reasons as well. Health care providers need to ensure that verbal communication is clear and frequent enough to compensate for low literacy. Any reading material intended for patients should be written at a level of grade 6 or below and drawings or graphics should be favoured over text and numbers.

Affordability

In principle, all Canadians have access free of charge to medically necessary physician and hospital services. However, extra-billing and user fees are a continuing problem, even though prohibited under the Canada Health Act.³⁵ Other costs reduce access: transport costs can be considerable, particularly in cases such as cancer which may require repeated visits to a specialist centre.

Services of non-physician professionals in the community are not included under the Medicare plan. Under the influence of federal direction and several reports on health care,^{8, 24, 36} provinces and territories are beginning to extend the range of publicly financed services to cover certain types of home care and some pharmacy care. Provinces and territories provide some community services for the most in-need populations, but others must pay directly or have private insurance for these services. Financial barriers to care, therefore, still exist, and may increase. As poverty is a major determinant of health, financial barriers further increase inequity in health; they ensure that those most in need of the service have least access to it.

Acceptability

Acceptability of services depends on a range of culturally determined factors that affect the expectations and attitudes of the user. Minority groups, such as immigrants, anglophones in Quebec, French speakers in other Canadian provinces, or Indigenous Peoples throughout Canada may feel ill at ease with services geared towards the expectations of the majority.^{37, 38}  In particular, poorly educated people on low incomes can find it difficult to negotiate their way through health services managed and delivered, as they are, by highly educated people with a relatively high income.

Information technology in health care

Information technology promises ways of managing health information to improve care, enhance the coordination of services, and streamline communication among care providers. Information technology also plays an important role in the application of research findings. But, in spite of the many organizations that disseminate evidence-based guidelines and models of excellence for practice, success in translating evidence into practice is still elusive. The field of knowledge translation research addresses this challenge.

Some developments in informatics that are of interest to clinicians include:

• Electronic medical and health records have been widely deployed. They provide efficient storage and retrieval of patient information; they can be built into local networks to allow quick transfer of information between hospitals and referring physicians, and they can be used for call and recall systems that facilitate preventive programmes and disease follow-up. A major concern is to ensure confidentiality when transferring information between institutions and offices; another is to develop compatibility between systems in building networks. Finally, electronic medical and health records, if the system is well designed, can provide useful information for evaluating practice performance.
• Telemedicine refers to the use of videoconferencing for medical care. This was widely adopted during the COVID-19 pandemic, and is now used by primary care providers, specialists, and other health professions. Variants include telemonitoring in which data from patients can be communicated to a specialist service; videoconferencing and its derivatives can be useful in bringing specialist services to remote areas. There have also been trials of telesurgery using robots or with video monitoring through which a specialist can guide a general surgeon.
• Teletraining. A number of services provide continuing web-based training for clinicians. Podcasts, videocasts and interactive training programmes are all available.

The Challenge of an Aging Population

There is widespread debate over the likely impact of the aging of the Canadian population on future demand for health services. Canadians are living longer and this, combined with the falling birth rate, means that the proportion of the population aged 65 or over is rising (See Figure 12.3).

It is widely understood that, as the average age of a population increases, the numbers of people with disability and chronic disease will rise, so health services should prepare to care for greater numbers of cases than the overall population growth would lead one to expect. However, set against this is the finding that people seem to be maintaining their health for longer, reducing the duration of ill-health a person experiences before dying. In 2017, 16.8% of the population was aged 65+ years, up from 13.4% in 2007. However, the fraction of health care spending on this group has actually declined, from 44.4% to 44.2%.⁶ This illustrates the concept of squaring the morbidity curve, shown in Figure 8.1.

Adults use health services most intensively in the four to six months before they die, no matter at what age death occurs. Analyses that control for the proximity to death shows that the major factor driving the use of acute services (and hence costs) is the number of deaths rather than the age of the population.³⁹ Costs can also increase with the intensity of intervention before death, noting that this may be the case with ‘heroic’ efforts provided to younger patients. Focusing on the aging of the population may be a distraction from the more pressing issue of how to allocate resources to care for people at the end of life. The growing use of medications, intensive interventions and high-technology equipment are major cost drivers. If professionals become more accepting of palliative care and if high quality palliative care becomes more available, the cost of care at the end of life could be reduced. This could reduce overall costs, although the increasing use of primary care services by the elderly and their greater need for long term care may in part offset this. Overall, the future influence of population aging is somewhat uncertain.

Health Services for Indigenous Canadians

Traditional Indigenous teachings highlight the importance of maintaining and restoring a balance among the physical, mental, emotional, and spiritual aspects of health through social and environmental sensitivity. These teachings were discounted by arriving Europeans who brought with them a way of life that threatened the lives and health of Indigenous peoples. Infectious diseases arriving with the immigrants had a devastating impact because Indigenous peoples had no immunity to them. Through colonization, the European way of life became more common while Indigenous peoples where forcibly excluded and disconnected from traditional ways of living. As a result, their health deteriorated compared to that of the dominant society. The health gap between many First Nations, Inuit and Métis communities and the rest of Canada broadened and to this day remains significant (see Chapter 2).

Health services alone cannot significantly reduce the health gap between Indigenous peoples and other Canadians. Reducing the gap would require attention to employment opportunities, income, education, social and physical environment, housing and sanitary infrastructures, as well as the restoration of traditional lands, governance and culture. Furthermore, despite the much greater service need among Indigenous peoples, their health services lack coordination. Although the federal government retains responsibility for providing care for a number of First Nations communities, the services are increasingly delivered by provinces, territories, and by band councils on reserves and in Indigenous communities. The services may not be well oriented towards the communities’ needs. They tend to be staffed by non-Indigenous people and, until recently, the First Nations communities had little say in the planning of services. There are no specific services for First Nations people living off-reserve. Mainstream institutions and professionals who serve Indigenous people living off-reserve rarely have the resources or training to provide culturally safe care.

In 2000, the National Aboriginal Health Organisation (NAHO) was established. Funded by Health Canada, it was an “Aboriginal-designed and -controlled body committed to influencing and advancing the health and well-being of Aboriginal Peoples by carrying out knowledge-based strategies.”⁴⁰ In the same year, the Institute of Aboriginal People’s Health was established as one of the Canadian Institutes of Health Research (CIHR) to support research and build research capacity in Indigenous peoples’ health.⁴¹ Funding for NAHO was cut in 2012, but the National Collaborating Centre for Indigenous Health continues the work of promoting Indigenous health through knowledge synthesis and dissemination, and by fostering linkages between Indigenous groups and the public health community. Nonetheless, the political nature of health service provision and the wide variety of issues to be addressed continue to create barriers to health for First Nations, Inuit and Métis Peoples and will likely do so for some time. NAHO closed in 2012.

The Occupational Health and Safety System

Occupational health and safety in Canada is largely addressed and administered by the provinces or territories, through their own legislation, government ministries and supporting agencies. Certain types of workplaces, however, are instead subject to federal legislation (i.e., the Canada Labour Code).  Despite differences among provinces, certain functions are common, including:

1)  Government regulators who protect worker health and safety and prevent illness and injury through enforcement of occupational health laws, and

2)  Workers’ compensation boards that help workers who have been injured or made ill due to work. Compensation covers lost earnings, out-of-pocket health care costs and non-financial losses (such as pain and suffering due to an illness/injury), and other expenses.

Other agencies that play a role in occupational health and safety include unions, industry associations, occupational health researchers, law firms, and associations that provide education and training to workers and workplaces, such as the Canadian Centre for Occupational Health and Safety.

Some workplaces have their own occupational health services, staffed by health care professionals (including physicians, nurses, case managers, ergonomists and others). The larger the workplace, the more complex their services may be.  An overview of the work of occupational health services is available.

Health and safety at work

• 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
• Right to refuse. Employees can refuse to do work that is dangerous to themselves or others and if the danger is not a normal condition of employment. A refusal is then followed up with an investigation to determine the risk involved and any steps needed to mitigate the risk.

The underlying philosophy is one of internal responsibility, meaning that everyone at a workplace shares responsibility for health and safety. This is often ensured through joint health and safety committees, which may be required depending on the number of workers and the laws that apply in that jurisdiction.  These committees have representation from workers and management and meet regularly to address health and safety concerns.

To enhance safety, workers are required to: use the safety equipment provided; respect health and safety procedures, instructions and policies that relate to the hazard or to the use of safety equipment and report potential workplace hazards as well as hazardous events and injuries.

Duties of employers are to provide a safe workplace; to respect safety standards, and to ensure that workers receive the necessary information and training to protect their health.  Each jurisdiction also has a “general duty” clause that employers must take all precautions reasonable in the circumstances to protect workers.

Other workplace parties that may have responsibilities under the law include supervisors, owners, and equipment suppliers.

Workers’ compensation

Organized workers’ compensation in Canada began with the 1913 Meredith Report and is administered by Workers’ Compensation Boards. A major goal of most Boards is to support sick or injured workers in returning to work. To aid this, compensation may cover rehabilitation costs, including, for instance, outpatient physiotherapy services. As such, workers’ compensation can extend the range of services provided by the provincial health care plan. The ill worker remains under the care of his or her usual treating physician who, on the patient’s request, must provide a letter to support the patient’s claim for compensation and must continue to monitor the patient’s condition. Apart from medical care, return to work may require changes in the patient’s work duties, involving, for instance, occupational therapists or occupational hygienists and the patient’s employer. The return-to-work process depends on shared responsibilities between employers, workers and health care providers, and often physicians are requested or even required to assist workers return to work safely.  Employers have a duty to accommodate workers who experience hardship due to any disabilities that require changes to how their work is normally performed.

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 often referred to as the Meredith principles:

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. Security of payment. Injured workers are assured of prompt compensation and future benefits.
3. 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.
4. 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
5. 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.

Public Health Services in Canada

Development of the public health system

Public health activities remained fairly uncoordinated until relatively recently. Historically, 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-19^th century, when immigrants brought cholera and typhus with them to Canada. In the early 20^th century some towns began to chlorinate water, rural towns began to pasteurize milk, and Ontario began to immunize against smallpox and diphtheria.

The 1974 Lalonde Report emphasized the need to look beyond the care of the sick in order to improve the health of the population, arguing that the health care system should include action on environment, lifestyles, 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, at the first international conference of health promotion being held in Ottawa, Jake Epp, the Minister for Health and Welfare, presented “Achieving Health for All: A Framework for Health Promotion.” This set out the direction for health promotion in Canada, as reflected in the Ottawa Charter for Health Promotion. It said that Canada should attempt to reduce inequities, to increase the prevention effort, and enhance people’s capacity to cope. It suggested that these could be achieved by fostering public participation, strengthening community health services, and coordinating public health policy.

For multiple reasons population and public health is often overshadowed by acute care and other personal health services in funding discussions. Depending on the year and jurisdiction, public health receives about 1.5% to 5% of overall health spending.^{42, 43}

There are differences in public health systems between provinces. For example, although most provinces structure their public health system in regional or provincial health authorities, Ontario relies on local public health units to deliver services. Similarly, British Columbia, Ontario, and Quebec have developed provincial Public Health organizations to provide technical and scientific public health expertise (BC-CDC in British Columbia, Public Health Ontario in Ontario, and the INSPQ in Quebec).

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 died, mostly in Toronto. 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 and disaster planning around the world.

These events demonstrated the weakness of our 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 of health;
• Provide leadership in promoting special health initiatives, and
• Improve the quality of public health practice.

The Act also created the Public Health Agency of Canada (PHAC), 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 public health 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, and
• Achieve greater success in attracting and retaining public health professionals.

In keeping with its origins, the Agency’s immediate priorities were health promotion and chronic disease prevention, infectious disease prevention and control, and health security.

Public health responsibilities in Canada

As described in an early report by the chief public health officer for Canada, public health is concerned with six essential activities:⁴⁵

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.
2. 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.

3. 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.
4. 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.
5. 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.
6. Emergency preparedness and response: Planning to tackle 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). (See details in Chapter 10).

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 populations, and the organization and range of services offered vary across the country.

Public health law

Because control of transmissible disease often requires changing behaviors in whole populations, from the earliest days public health actions were underpinned by legal sanctions. Much of public health law was drawn up in the 19^th century when the discipline of public health was gaining recognition. Public health law is still evolving and Quebec was the first province to develop a sophisticated system that was consolidated by its adoption of its Public Health Law in 2001. Now, every province and territory has relevant public health legislation.⁴³ Public health law is based on the following principles:⁴⁷

• The government has a duty to protect the health and well-being of the population by providing public health services.
• In doing this it holds the authority to set standards of health and safety, and the power to constrain individuals who may pose a risk to the public’s health. It has the authority to ensure compliance with these standards.
• At the same time, it must exercise restraint in the use of this power; it should act only on the basis of clear criteria and respect due process.

The Clinician and the Health System

A well-functioning health system has five main objectives according to the World Health Organization. Although an individual physician is a very small part of the system as a whole, collectively physicians play a huge role in ensuring that these objectives are attained. The following sets out the objectives and what is required of physicians to meet the objectives:

• A health system improves the health status of individuals, families and communities: Physicians maintain a high standard of care by keeping up to date on best practices in health promotion and treatment and prevention of illness. They ensure that the care provided meets the needs of patients, families and communities. In particular, they collaborate with other professionals to provide the appropriate care at the appropriate moment in the appropriate setting.
• The system defends the population against health threats: Physicians identify threats by participating in surveillance systems that identify threats early, for instance the notifiable disease system. They contribute to limiting the impact of threats, for instance by providing prophylaxis to contacts of infectious disease. They prevent adverse effects of care by judicious prescribing (antibiotics only when indicated), by introducing and adhering to systems that prevent error (marking the area on which to operate while the patient is still awake and able to confirm), by respecting guidelines for infection control and by ensuring that communication with patients, families and other professionals is clear and understood. Finally, physicians advocate for people with adverse health determinants.
• Protection against the financial consequences of ill health: Physicians tailor their advice to the patient’s financial resources and situation. They do not advise joining a gym to get exercise when the patient has difficulty feeding herself and her family or when she works hard at a physically demanding job. They realise that workers may lose wages by taking the time to attend medical appointments and practical considerations such as transport and child care can make appointments costly. They advocate for people whose ill health has resulted in inability to get work or to keep working, full-time or at all. Finally, they collaborate with professionals who can help people get all the benefits to which they are entitled and they identify work-related illnesses and encourage the patients to claim benefits.
• Providing equitable access to people centred care: Physicians ensure that those most in need of healthcare have the access they need. It may be that clinic hours suit people who are constrained by long working hours or availability of child care. Physicians practice in areas where vulnerable populations are found and make sure that people without transport or with disabilities can get to the clinic. If the clinic serves an immigrant population, the physician arranges for interpretation services. Physicians and clinic staff are open to cultural differences. Outreach systems may be necessary to ensure that preventive services are used.
• Involving people in discussions of their own health and the health system: Physicians make sure that patients understand their condition and the risks and benefits of management options. They know which referral services best respond to their patients’ needs. They put patient goals first when developing a management plan. They look for patients’ opinions on the services they and their collaborators provide.

Self-test Questions

References

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