Technology for Care
5.1 INTRODUCTION Canada’s population is 33 million people. The land area is 3,854,082 square miles (Infoplease, 2010). Eighteen percent of Canada’s population is under 15 years old (UNO, 2004), and 17% of the population is over the age of 60 (WHO, 2004). The primary languages spoken in Canada are English and French. The largest ethnic groups are British, French, and other European groups. The largest religious groups are Roman Catholic with a strong presence of Anglican and other Christian religions ( who.intl/profiles_countries ). Canada is ranked 25th out of 31 countries in the literacy rate. Because demand for health services is so high, Canadians often must wait a long time for appointments to see the doctor, especially in the province of Quebec. In the words of Frogue (2001, p. 10), “everything is free but nothing is readily available.”
5.2 HISTORICAL Dating back to 1867 Canada’s Constitution assigned most of the healthcare responsibilities to its ten provinces and three sparsely populated northern territories. These provinces vary widely by size and fiscal capacity. For example, in 2001, Prince Edward Island had a population of 135,000 while Ontario had 11.4 million.
Canada, unlike the United States, provides universal health coverage, a national health insurance program provided by the Medical Care Insurance Act of 1966. Universal coverage provides health care to all members of its society, combining mechanisms for health financing and service provision (WHO, 2008). Health care in Canada is funded through general taxes and Medicare. The National Medical Care Insurance Act operates on the basis of four principles: 1) it is comprehensive, covering all medically necessary services provided by physicians, 2) universal coverage is available to all legal and illegal residents, 3) it is publicly administrated, either directly by provincial government or by an authority directly responsible to it, and 4) it is portable.
The Canada Health Act, passed in 1984, established a fifth core principle, accessibility, which sought to force provinces to forbid extra billing and cost sharing. It called for the Canadian government to deduct the amount of such charges from its payments to any province.
During the early 1990s there were growing concerns about the perceived notion that the country was approaching physician saturation, even the potential for a surplus. This led to policy decisions such as enacting a 10% cut in first year medical school admissions, contributing to a drop in physician supply.
5.3 STRUCTURE Canada has a readily available supply of physicians, and less availability of nurses. Levels of nurses practicing in Canada are comparable to those in the United States and include registered nurses, nurse practitioners, nurse midwives, and LPNs. However, nurse practitioners and physicians assistants are relatively new to Canada and are not yet widely utilized. Other health professionals in Canada include dentists, pharmacists, medical and radiology technicians, chiropractors, and physiotherapists.
In 2004, workforce aging became a significant challenge in that health professionals were aging more rapidly than the Canadian population with the average physician being 49 and the average RN being 45. Between 1990 and 2005, the number of nurses practicing in Canada decreased from 11.1 to 10 nurses per 1,000 population, with the lowest point occurring in 2003, at 9.6 per 1,000 (OECD Health Data, 2007). Also, increasing numbers of women are entering the medical workforce.
According to OECD (2007) data, 24% of Canadians live in rural areas, yet only nine percent of the physician workforce practices in rural Canada. Although Canada has a stable supply of physicians, in 2008 approximately 14% (5 million) of Canadian adults did not have a family physician. Between 2002 and 2006, permanent migration of physicians to other countries tripled and temporary migration increased over 10%. Permanent migration of nurses increased by 40%, and temporary migration increased by 35%. In 2006, 9% of all nurses and 19% of physicians born in Canada were working in other OECD countries. Physicians also move freely among provinces, in fact 62.3% of the physicians in Canada are concentrated in the two provinces of Ontario and Quebec. Although the number of male registered nurses almost tripled from 1985 to 2006, from 5,000 to 14,000, they make up only 6% of Canada’s nursing workforce and more than half the male nurses in Canada practice in Quebec. Physicians from South Africa, and nurses from the Philippines also are part of the Canadian workforce (OECD, 2007). Many of the nurses working in the United States in the travelling nurse program were Canadians.
Canada regulates physician supply, physician and hospital budgets, and technology. The government also coordinates financing, insurance, and payment function. Unlike the American healthcare system, because the Canadian healthcare system is government run there is no need for employer involvement in health care except, of course, for supplemental catastrophic additional coverage. The role of payers is limited to the government and individuals. The role of insurers in Canada is minimal.
5.4 FINANCING
During the 1970s physicians commonly billed patients for additional costs that were already covered by the government plan. In 1984, the passing of the Canada Health Act prevented medical providers from billing patients for services if they had also billed the public insurance system. A reaffirmation of the government’s stance that they were committed to health care that was, “comprehensive, universal, portable, publically administered, and accessible,” was issued by the Prime Minister in 1999. Portable means coverage continues when patients travel or move between provinces.
Single payer is used to primarily describe a system that is government funded and controlled. Canada has a single payer system, complemented by insurance and direct out-of-pocket payments. There are global budgets for hospitals and physicians, negotiated fees for services, and consumer co-payments. Hospitals and physicians must operate within a set budget with which they must strictly adhere. In order to finance Canadian health care, provincial funds are gathered from a mix of federal transfers that favor poorer provinces, general provincial revenues, employer payroll taxes, and insurance premiums.
In provinces like Alberta and British Columbia where premiums exist, there are special provisions for assistance to people with low incomes. Residents of each province receive insurance cards, which they present when being seen in a hospital or physician office. They must produce this card for care because benefits vary slightly among provinces. There is typically no general dental coverage, but most provinces provide some pediatric dentistry, and all provinces cover in-hospital oral surgery as part of hospital coverage. Many provinces provide limited optometric, chiropractic, and physical therapy coverage. Financial support for pharmaceutical expenses is included in separate programs, generally for seniors and other categories of the needy. Contraception is available to all women in Canada free of charge as birth control is also covered under the public insurance plan. Every provincial plan insures all medically necessary physician and hospital care.
Private insurance is allowed for what is referred to as non-core services. Private insurance plans are prohibited from billing patients for core services, or any service covered by the standard public insurance plan. An estimated 80% of Canada’s population has supplementary coverage for items such as private rooms, dental care, and other non-core services (Irvine, Ferguson and Cackett, 2002, p. 17). This is financed primarily through employers, and, as in the United States, is treated as a business expense for tax purposes.
5.5 INTERVENTIONAL
The social and economic conditions experienced by a people have a definite influence on their health status. Any proposed interventions must be geared toward addressing health issues within the realm of these conditions.
Despite problems with access, and language challenges that are closely related to cultures other than French, there is a high user satisfaction with health care in Canada. Canada places less reliance on technology and there is greater access to health providers in urban settings. However, there are often long waits for appointments and services. In 2005, on average, Canadians waited 12.3 weeks for an MRI, 5.5 weeks for a CT scan and 3.4 weeks for an ultrasound (Fraser Institute, 2005). Almost half of the Canadian public, when surveyed by Pollara polling in 2005, reported their willingness to pay out-of-pocket for faster access to services (Irvine et al., 2005, p. 59). Absenteeism and turnover rates for nurses are also high. For example, absenteeism rates for full time RNs was 83% higher than it was for the general labor market. The Canadian government paid 962 million C$ in absentee, overtime, and replacement wages among nurses in 2007 (Drebit, 2010).
Health care for older adults in Canada is plagued by major long-term care challenges, lengthy waits to gain admission into nursing homes, and poor quality of care.
5.6 PREVENTIVE Approaches to addressing health promotion and disease prevention in Canada are perhaps as diverse as the population. Indigenous to Canadian society are the Francophones that include the Mètis, Native American and European descendants, and the Acadians, descendants of the early French colonists. Canada, with its multiethnic, multilingual, and cultural mosaic is a melting pot of diversity (Coutu-Wakulczyk, Moreau, and Beckingham, 2003, p. 160).
Despite Canada’s nearly perfect literacy rate (approximately 99%), illiteracy is high among the Francophones and the elderly. In fact, in some communities, Canada’s high school drop-out rates exceed 40%, highest in poor and rural areas, especially for Aboriginals and Francophones, and among boys (Office of Francophone Affairs of Ontario, 2000). Another problem is obesity and obesity related hypertension especially among women. Pausova et al. (2000) believe these are attributed in great part to the TNF-α gene locus.
There has been a steep decline among Francophones in fertility rates from 4.95 children for the period 1956–1961, to 1.57 from 1991–1996 leading to the concern about long-term viability of Francophones outside Quebec especially since they have very little access to healthcare services where providers speak French (Office of Francophones Affairs of Ontario, 2001, Chung, 2009). Ansen (2000) found among Francophone women, the more educated the women the lower the
fertility rate. Edwards and Rootman (1993) reported the responses of Canadians aged 15 and older who were asked about practices for improving health. In order of importance they identified smoking cessation 81%, increased relaxation 69%, exercise 65%, income security 45%, quantity of time spent with family 45%, weight loss 42%, better dental care 27%, job changes 22%, reduced drinking 16%, moving 14%, and reduced drug use 9%.
Canada’s government-focused initiatives to address promotion of health and prevention of disease include specific programs to address obesity and the dissemination of health information via hard copy and online, keeping in mind that if the information is not disseminated in minimally English and French it will not likely be beneficial. Education always appears to be a key indicator in preventing illness.
5.7 RESOURCES Men appear to be the hallmark of the Canadian society. They are typically viewed as the moral authority, and the one responsible for providing for, and protecting the family. Women, on the other hand, are charged with responsibility for running the household, child care, and caring for family members when ill (Langelier, 1996). For childbearing women, midwives and maternity centers are commonly used.
In some segments of Canada’s population, family, extended family, and clergy are particularly supportive in the care of persons at or nearing the end-of-life. For example, African Canadians account for more than half (52%) of Nova Scotia’s visible minorities (Statistics Canada, 2003). According to Clairmont and Magill (1970), years of poor living conditions, racism, hostile treatment, and a widespread lack of acceptance and integration into Nova Scotia society has led to the creation of a Black community that has been oppressed. Rather than seeking help from the healthcare system, many persons of African descent draw heavily on each other for support when challenged by an illness. Crawley et al. (2000) describe the rich religious tradition among African Americans in explaining some of the behaviors of African Canadians. The authors explain that in considering the omnipotence of God, if they do not receive a healing miracle, they often welcome death as a “home going.”
5.8 MAJOR HEALTH ISSUES Canadians are plagued by troubling diseases that often result in death, with cancer leading the way. Although the incidence of smoking is trending down, lung cancer is still the leading cancer killer in Canada for men and women (The Canadian Cancer Society, 2007). Heart disease and stroke rank
as the second and third leading causes of death in Canada. The WHO (2010) record of the top ten diseases causing death in Canada are as listed in Table 5-1 .
5.9 DISPARITIES The top three diseases, cancer, heart disease, and stroke, in Canada are treated similarly to the United States. There are many similarities and differences in treatment approaches among Canadian provinces. Whether health outcomes are positive or negative they are influenced by social determinants such as population, poverty, age, race/ethnicity, and gender.
Table 5-1 Top 10 causes of death (all ages) in Canada, 2002, with the number and percent of years of life lost by disease.
Source: Death and DALY estimates by cause, 2002.
http://www.who.int/entity/healthinfo/statistics/bodgbddeathdalyestimates.xls
SUMMARY There are many more strengths in the urban healthcare area than rural among Canadian provinces. It is important for Canada to build a workforce that is more sustainable and effective at meeting the needs of its residents both rural and urban. Recruitment and retention incentives may be effective ways to address these two important workforce issues.