Professional Documents
Culture Documents
Health and Delivery DH-03
Health and Delivery DH-03
Health and Delivery DH-03
THIRD EDITION
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
Summary
Review questions
Summary
Review questions
Drug Plans
Summary
Review questions
Conclusion
Summary
Review questions
Practice settings
Summary
Review questions
Population health
Determinants of health
Review questions
Health models
Summary
Review questions
Summary
Review questions
What Is Ethics?
Ethics at work
End-of-life issues
Allocation of resources
Summary
Review Questions
Drug coverage
Indigenous health care
Summary
Review Questions
Declaration
Glossary
Index
Copyright
ELSEVIER
ISBN: 978-1-77172-169-1
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 be er 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 se ling 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
be er 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 a aches 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 Se ings) provides the
student with a clear picture of the current state of our health human
resources—who delivers the care, in what se ing, 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,
p g
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
g y gy g
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
h p://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
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
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
Sources: Rice, W. (January 18, 2016). Eagle feathers now on hand for oaths at
O awa courthouse. Retrieved from
h p://www.cbc.ca/news/canada/o awa/eagle-feathers-now-on-hand-for-
oaths-at-o awa-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. Gaze e (Vol. 79, No. 4). Retrieved
from www.rcmp-grc.gc.ca/en/gaze e/eagle-feather-flies-nova-scotia-
detachments.
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 Se lement in 2007
resulted from lobbying and pressure from Indigenous people who
had a ended residential schools; this was followed by a formal
apology by then Prime Minister Harper in 2008. The se lement
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 se lement 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
se lement 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 h p://www.fnha.ca/wellness/our-history-our-health.
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.
Box 1.2
Innovation in Newfoundland: The Cottage
Hospital System.
In the 1930s approximately 1 500 communities in Newfoundland
were sca ered across 7 000 miles of coastline. To service these
communities the provincial government developed the Co age
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 co age
hospitals, including transfer to the nearest base hospital when
necessary.
Not only was Newfoundland’s co age 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.
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.
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).
Box 1.3
Legislation Leading up to the Canada Health Act.
The Hall Report (1960)—Royal Commission on Health
Services
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).
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
h p://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
h p://www.res.parl.gc.ca/Content/LOP/ResearchPublications/944-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 se ing,
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).
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.
p
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 ma er 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.
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 permi ed 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.
Accessibility
The criterion of accessibility was added to the Canada Health Act in
an a empt 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.
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.
Box 1.7
Alternative Health Care Strategies.
New Brunswick was one of the first jurisdictions to predict the
problems related to funding shortfalls, cutbacks, population
changes, and an increased need for hospital beds. The province led
the move toward community-based care, called “hospital without
walls,” and established the Extra-Mural Program, which focused on
shortening hospital stays and providing the appropriate care and
support to meet health care needs in home and community se ings.
This concept was actually introduced in 1979, 5 years before the
Canada Health Act was passed.
Throughout the 1980s and 1990s, various provinces and territories
completed investigations into the state of health; of several, these
include: the Royal Commission on Health Care in Nova Scotia
(1989), Commission on Directions in Health Care in Saskatchewan
(1990), Premier’s Council on Health Strategy in Ontario (1991), and
the Health Services Review in British Columbia (1999).
National reports were also commissioned—for example, the first,
second, and third reports on the health of Canadians, released in
1996 and 1999 and 2003, respectively, examined and summarized
the health status of Canadians. A 2016 report on the Health of
Canadians focused on the growing number of Canadians with heart
disease.
By 2002 public confidence in health care was at an all-time low,
with health care topping the list of Canadians’ concerns. Following
this concern grew around the services (or lack thereof) for mental
health, community care, and the omission of a national pharmacare
strategy. Provinces and territories introduced a variety of
commissions to study varying concerns regarding health care
within their own jurisdictions, some coming to fruition, others not.
On a national level, over a number of years, responding to gaps in
mental health and homecare services became a priority. In 2006, the
Senate Standing Commi ee on Social Affairs, Science, and
Technology completed a Canada-wide study on mental
health/illness, recommending, among other things, establishing a
Canadian Mental Health Commission to address shortcomings in
mental health services. The Mental Health Commission of Canada
(chaired by the Honourable Michael Kirby) was created the
following year to provide and oversee mental health services at a
national level. Creation of the Mental Health Commission of
Canada was supported by all jurisdictions, except Quebec.
In 2017, the federal government provided targeted funding for
both mental and community care initiatives. Medically assisted aid
in dying was legalized in response to national pressure to provide
dying with dignity, procedures deemed to be the responsibility of
primary care practitioners, and overseen by family physicians, and
nurse practitioners.
Only recently have Canadians become more concerned about the
environment than health care. Ironically, environmental concerns
(e.g., pollution, contaminated drinking water, poor air quality)
squarely interact with health care concerns.
Medical Model of
Primary Health Care Reform Goals
Health Care
Physician-based Team-oriented care
care
Illness-focused Emphasis on disease prevention and health promotion
Hospital-based Community-based care
care
Curative (in Treating maladies, which sometimes results in living
relation to disease) healthy lives with chronic conditions
Problems are Care is comprehensive and integrated (i.e., holistic)
isolated
Health care Collaborative care involving interdisciplinary teams,
provider– patient, family, and loved ones
dominated
Social Union
In 1997, the provincial and territorial first ministers met with their
federal counterparts to form a social renewal program that required
that all governments work collaboratively on what the first ministers
called a social union (Social Union, 1999). The agreement
acknowledged the need to establish national standards for social
rights and associated related policies.
The principals of the covenant included being recognized equally
for all Canadians. All Canadians should be treated with fairness and
dignity and equality of rights; they should be afforded equal
opportunities and provided appropriate assistance for those needing
it; and they should be afforded mobility within Canada. Mobility
means Canadians can move freely within the country to see
opportunities, and governments will remove any residency-based
barriers. Canadians have the opportunity to use monetary transfers
from support social programs such as health care.
Difficult negotiations followed, primarily around the federal
funding formula and the amount of autonomy provinces and
territories would have with respect to where and how to spend the
money (e.g., cancer treatments, improvements to emergency
departments, long-term care). The final agreement was signed by all
jurisdictions, with the exception of Quebec, on February 4, 1999
(Asselin, 2001). Quebec was unwilling to sign any agreement that
did not clearly support the province’s right to unconditionally opt
out of programs supported by or initiated by the federal
government, which the social union did not provide.
In the final agreement, the union agreed to maintain the five
criteria of the Canada Health Act and to work continuously to
improve health care. Also included was a commitment to work
collaboratively with Indigenous people, their governments, and their
organizations to improve health care and social programs. The
federal government then promised to boost health care spending by
$11.5 billion over the next five years, which began in the 1999–2000
fiscal year.
The success of the social union today is questionable at best.
Federal funding formulas changed (see Chapter 8), and the
agreement drove a wedge between Quebec and the federal
government; certainly inequities related to social programs are
evident. Consider the rise in the rate TB among our Indigenous
population, particularly the Inuit population, which in 2017 was
estimated to be an astounding 290 times higher than in non-
Indigenous Canadians.
Commissioned Reports
By the end of 2002, three major reports on the status of health care in
Canada had been commissioned and released: the Mazankowski
Report, the Kirby Report, and the Romanow Report. See Box 1.8 for
the key points of each report.
Box 1.8
Three Major Reports on the Status of Health Care
in Canada.
The Mazankowski Report: A Framework for Reform (2001)
Commissioned by former Alberta premier Ralph Klein in August 2000 and
chaired by Donald Mazankowski, former Cabinet member in the Mulroney
government
Purpose: to provide strategic advice to the premier on the
preservation and future enhancement of quality health services for
Albertans
Key Points
Thinking it Through
Despite past recommendations to establish a national drug plan
(e.g., The Romanow Report) to date, this has not been done. Some
claim that a national drug plan would be cost prohibitive, others
claim that a national plan would be cost effective and save billions
of dollars. The federal government, as part of the 2018 budget,
announced the creation of an Advisory Council on the
Implementation of National Pharmacare to assess the impact such a
plan would have for Canadians and the health care system.
Other Initiatives
In addition to meetings and policies made at the federal level, all
provinces and territories promote health care initiative within their
own jurisdiction. Decisions as to what these programs and policies
encompass involve politicians, other stakeholders at all levels as well
as individuals living in that jurisdiction. A good example is the
Patient First Review launch in 2008. A survey was conducted using a
variety of methodologies asking people if the Saskatchewan health
care system was pu ing the patient first, and if they felt the system
was being run in an efficient manner (both from a monetary and
service perspective). This framework of proposals and
recommendations is reviewed at regular intervals—the last in 2015.
E-Patient and Family-Centred Care (PFCC) Framework has
improved the health care in a number of ways (e.g., lowering
surgical wait times).
Summary
1.1 Health care in Canada evolved from European se lers’
bringing doctors and nurses (many of them with the
military) to the country in the 1500s and 1600s and
integrating many of their practices with those of the
Indigenous peoples. In the 1700s and early 1800s, volunteer
organizations played a key role in the delivery of health care.
The concept of public health emerged in the early 1800s, and
with the passage of the British North America Act in 1867,
federal and provincial governments shared responsibilities
for health care, which, over time, became more structured
and formalized. As a result, some government funding of
hospitals began around this time, and the first school of
nursing was established in 1873 in St. Catharine’s, Ontario.
1.2 Traditional ceremonies and practices of First Nations people
date back centuries. Indigenous people were healthy and had
numerous ceremonies and practices that were handed down
over the years, orally, for the most part. Thus there are few
wri en records of these practices. Most cultural practices
were rooted in holistic and spiritual ideals and beliefs as well
as an integral relationship with nature and “mother earth.”
With colonization, western medicine was deemed more
effective. Today across Canada there is a move to integrate
traditional health practices and traditions with Western
medicine and sometimes replace Western treatments.
1.3 The road toward health insurance began with the first
federal a empt to introduce a publicly funded health care
system in 1919. Following World War II, governments began
thinking that they had an obligation to provide Canadians
with a be er standard of living, including access to quality
health care. Prepaid hospital care was introduced in 1948 and
was well received by all jurisdictions. Shortly afterward,
Saskatchewan spearheaded an organized push to integrate
both medical and hospital care into the public health care
system.
1.4 With the federal government commi ed to a comprehensive
national health care system, a number of reports and pieces
of legislation followed. The Hall Report, the Medical Care Act,
and the Established Programs and Financing Act all played
significant roles leading up to the Canada Health Act. In 1957,
the federal government introduced the Hospital Insurance and
Diagnostic Services Act, which was the precursor to prepaid
health care for all Canadians. Prepaid health care as we know
it today came into effect in 1984 with the passage of the
Canada Health Act.
1.5 The five criteria established by the Canada Health Act of 1984
for the delivery of health care are public administration,
comprehensive coverage, universality, portability, and
accessibility. The two conditions included in the Act are
information and recognition. The Canada Health Act
specifically outlines extended health care services that are
considered medically necessary and are thus insured.
Medically necessary is a subjective term that has been debated
within the context of the Canada Health Act; extra billing and
user charges are permi ed only for services deemed not
medically necessary under the Act.
1.6 There was some opposition to the Canada Health Act by
physicians and the Canadian Medical Association on the
grounds that it restricted extra billing and user charges and
violated professional freedom. In the decade that followed
the implementation of the Act, increasing difficulties in the
health care system led some provinces and territories to
establish innovative health care strategies, and primary
health care reform began to take place. In 1997, the first
ministers met with the federal government to work toward a
social union and clarify the role of the federal government
with respect to funding. By the end of 2002, three major
reports on the status of health care in Canada had been
commissioned and released: the Mazankowski Report, the
p
Kirby Report, and the Romanow Report. Several first
ministers’ meetings over the past 15 years have resulted in
the creation of new health accords.
1.7 The health accord negotiated under Prime Minister Paul
Martin provided provinces and territories with a funding
model lasting until 2014. Federal transfers guaranteed
jurisdictions an increase of 6%/year until that time. The
Harper government, in 2014, unilaterally imposed an accord
that reduced the CHT transfer amount to 3%/year, or to the
percentage of the GDP.
1.8 The 2017 accord negotiated (again unilaterally) by the
Trudeau government kept the same formula for the CHT, but
offered additional funding aimed as specific services (home
care and mental health). Provinces and territories initially
presented a unified front, refusing the terms of this take it or
leave it deal. The federal government offered to negotiate
privately with each jurisdiction, and slowly, provinces and
territories signed individual agreements.
1.9 The 2003 health care renewal accord introduced the Canada
Health Transfer, reexamined the process for evaluating
equalization payments, and established the compassionate
care benefit package. In this Accord, The Health Council of
Canada was given increased responsibilities to report to
Canadians on health outcomes.
Review questions
1. What were the health care responsibilities of the federal and
provincial governments outlined in the British North America
Act?
2. What organizations a ended to the health care needs of
Canadians in the eighteenth and nineteenth centuries?
3. What are three traditional healing practices of Canada’s
Indigenous population? Briefly describe them.
4. How and when was health insurance first introduced in
Canada?
5. How and when was the concept of prepaid hospital care
introduced in Canada?
6. List and describe three pieces of legislation that played
significant roles leading up to the creation of the Canada
Health Act.
7. What are the criteria and conditions of the Canada Health Act
and what do they mean?
8. What is meant by the terms medically necessary, extra billing,
and user charges, and how do they relate to each other in the
context of the Canada Health Act?
9. What are the goals of primary care reform?
10. Why was the Indigenous population in Canada so affected
by disease when non-Indigenous people came to Canada?
11. Describe two healing ceremonies important to First Nations
people in Canada. Which ones are practised today?
12. How did residential schools affect the Indigenous population
in Canada?
13. List and describe three major reports on the status of health
care in Canada.
References
Asselin R.B. The Canadian social union: Questions
about the division of powers and fiscal federalism.
Library of Parliament. Retrieved from
h ps://lop.parl.ca/Content/LOP/ResearchPublication
s/prb0031-e.htm. 2001.
Canada Health Act. RSC c. C-6. 1985.
Canadian Blood Services. Guidelines for the Canadian
Blood Services Summer Internship Program 2014.
O awa: Author; 2014. Retrieved from
h ps://blood.ca/sites/default/files/guidelines-sip-
2014.pdf.
Canadian Museum of History. A brief history of
nursing in Canada from the establishment of New
France to the present. Retrieved from
h ps://www.historymuseum.ca/cmc/exhibitions/tres
ors/nursing/nchis01e.shtml. 2004.
Canadian Red Cross. Historical highlights. Retrieved
from h p://www.redcross.ca/about-us/about-the-
canadian-red-cross/historical-highlights. 2008.
Dacey E., Glowacki L. Manitoba final province to sign
health-care pact with feds. CBC News. Retrieved from
h p://www.cbc.ca/news/canada/manitoba/funding-
health-manitoba-1.4255391. 2017.
First Ministers. (2003). First ministers’ accord on health
care renewal, O awa: Author. Retrieved from
h p://www.hc-sc.gc.ca/hcs-sss/delivery-
prestation/fptcollab/2003accord/nr-cp_e.html.
First Ministers. First ministers’ meeting on the future of
health care 2004: A 10-year plan to strengthen health
care. Retrieved from h p://www.hc-sc.gc.ca/hcs-
sss/delivery-prestation/fptcollab/2004-fmm-
rpm/index-eng.php. 2004.
First Ministers. Annual conference of Federal–
Provincial–Territorial Ministers of Health. Retrieved
from
h ps://www.canada.ca/en/news/archive/2005/10/ann
ual-federal-provincial-territorial-ministers-health-
conference.html. 2005.
Government of Canada, Health Canada. Canada
reaches health funding agreement with Ontario
[Press release]. Retrieved from
h ps://www.canada.ca/en/health-
canada/news/2017/03/canada_reaches_healthfunding
agreementwithontario.html. 2017.
Kelowna Accord. Aboriginal roundtable to Kelowna
Accord: Aboriginal policy negotiations. 2006.2004–
2005. Retrieved from
h p://parl.gc.ca/information/library/PRBpubs/prb060
4-e.htm.
Mental Health Commission of Canada. Advancing the
mental health strategy for Canada: A framework for
action (2017–2022). O awa: Mental Health
Commission of Canada; 2016. Retrieved from
h ps://www.mentalhealthcommission.ca/sites/defaul
t/files/2016-
08/advancing_the_mental_health_strategy_for_canad
a_a_framework_for_action.pdf.
Mount Saint Vincent University. Formal training for
nurses, the beginning. Retrieved from
h p://www.msvu.ca/library/archives/nhdp/history.h
tm. 2005.
New Brunswick, Office of the Premier. (2016, December
22). Revised: Canada-New Brunswick health accord
signed [Press release]. Retrieved from
h p://www2.gnb.ca/content/gnb/en/news/news_rele
ase.2016.12.1242.html.
Picard A. Krever inquiry. In: The Canadian
Encyclopedia. 2014. Retrieved from
h p://www.thecanadianencyclopedia.com/index.cfm
?PgNm=TCE&Params=A1ARTA0009152.
Social Union. A framework to improve the social union
for Canadians: An agreement between the
Government of Canada and the governments of the
provinces and territories. Retrieved from
h p://socialunion.gc.ca/news/020499_e.html. 1999.
St. John Ambulance. St. John Ambulance’s history in
Canada. Retrieved from
h ps://www.sja.ca/English/About-Us/Pages/SJA-
History-in-Canada.aspx. 2018.
The UN Refugee Agency [UNHCR]. Canada’s 2016
record high level of rese lement praised by UNHCR.
2017. Retrieved from
h p://www.unhcr.org/news/press/2017/4/58fe15464/c
anadas-2016-record-high-level-rese lement-praised-
unhcr.html.
Tommy Douglas Research Institute. (n.d.).
Achievements. Retrieved from
h p://www.tommydouglas.ca/tommy/achievements/
.
Until the Last Child. The history of child welfare in
Canada. Retrieved from
h p://www.untilthelastchild.com/the-history-of-
child-welfare-in-canada/. 2014.
Wilson K. The Krever Commission—10 years later.
CMAJ. Canadian Medical Association Journal. 2007.
;177(11):1387–1389.
h ps://doi.org/10.1503/cmaj.071333.
2
The Role of the Federal Government in
Health Care
LEARNING OUTCOMES
KEY TERMS
Branch
Bureau
Hypoglycemic reaction
Indigenous Peoples
Inuit
Pandemic
Patented drugs
Risk assessment
Severe acute respiratory syndrome (SARS)
How much influence does the federal government have over our
health care? Who pays for health care for refugees who have not
established residency in Canada? Are there any conditions on the
extent of health care they receive? What department is responsible
for licensing health products that come onto the market, and who is
responsible for overseeing the safety of food, the use of insecticides
on our crops, and the type and the cost of medications on the
market? What is in the flu vaccine, and why should we get it? How
does the World Health Organization (WHO) actually track health
threats? What level of government is responsible for making
recommendations regarding the numbers of nurses required across
the country? To answer most of these questions, one must
understand the role of the federal government in health care.
The federal, provincial, and territorial governments all play a part
in health care. As noted in Chapter 1, the responsibilities of each
were originally outlined in the British North America Act in 1867.
Today, the federal government possesses li le power over the health
care of individual Canadians and absolutely no legal power over
health care delivered in provincial and territorial jurisdictions. The
provinces and territories continually guard their authority over
health care in their individual relationships with the federal
government. On the other hand, the provinces and territories want
and need federal financial support, which comes with stipulations.
In fact, it is through its control over medical and hospital care
funding that the federal government exerts most of its influence.
The federal government also provides leadership, advice, and
direction on health care issues on a national and international front.
International issues require Health Canada to interact regularly with
global organizations, particularly the WHO, which has become more
visible over the past several years, especially with respect to issuing
warnings and bulletins about regional and global health threats. The
Ebola Viral Disease outbreak in west Africa and appearance of the
Zika virus outbreak which spread through the Americas in 2016 are
two such global health threats.
This chapter examines the role of the federal government in health
care, the hierarchical structure of Health Canada, and the functions
of the various government departments and agencies. The chapter
begins by looking at Health Canada’s mission statement,
philosophy, and commitment to health care in Canada. These
pledges provide the foundation upon which the ministry was built
and the values with which it strives to function. Despite the best of
intentions, however, many issues are not addressed effectively and
consistently, so problems with the Canadian health care system
persist today.
Health canada: objectives and responsibilities
Health Canada is the federal government department responsible for
health ma ers. Headed by a minister of health, it consists of a
number of sub-departments organized into functional and
administrative branches, agencies, and offices. Since Health
Canada’s organizational structure changes frequently, this chapter
discusses only the ministry’s major components, with a focus on the
primary responsibilities of each. Refer to the Health Canada website
for information about any recent changes to the organizational
structure and allocation of responsibilities (h p://www.hc-sc.gc.ca).
Health Canada’s detailed mission statement includes information
about its purpose, values, and activities. It states that Health Canada
is “commi ed to improving the lives of all of Canada’s people and to
making this country’s population among the healthiest in the world
as measured by longevity, lifestyle and effective use of the public
health care system” (Health Canada, 2016a).
With a mandate to provide national leadership for health care and
to maximize health promotion and disease prevention strategies,
Health Canada has commi ed to working collaboratively with the
provinces and territories on joint ventures such as creating policies
and financing projects. The ministry manages funding policies and
oversees the transfer of money and tax points (explained in Chapter
1) to the provinces and territories for health, education, and social
programs. The 2017 Health Accord saw the majority of jurisdictions
negotiating their own agreements with the federal government for
health care funding. Health Canada also plays an authoritarian role,
ensuring the provinces and territories remain compliant with the
Canada Health Act and enforcing penalties on those that function
outside of the principles within the Act. Health Canada may restrict
funding to noncompliant provinces and territories.
As a service provider, Health Canada remains responsible for the
majority of health care services for Indigenous communities, the
armed forces, veterans, and correctional services employees. In 2012
the federal government passed responsibility for the RCMP to the
province or territory in which they reside.
Services offered through the Interim Federal Health Program
(IFHP), authorizes (temporary) basic health care coverage for
protected persons, refugee claimants, and rese led refugees who do
not qualify for provincial or territorial coverage. This coverage
includes supplemental coverage includes limited vision and dental
care, and drug benefits. Syrian refugees brought to Canada had
immediate health coverage and were given resident status upon
arrival.
Refugee claimants are citizens of other countries who arrive in
Canada claiming refugee status because they need protection from a
threat or danger in their country of origin. Until a refugee claim is
se led, the federal government retains responsibility for the
claimant’s health care needs.
In addition to basic health care (similar to what is provided to
Canadians in the provinces and territories), Indigenous Peoples on
reserves who are recognized by an Inuit land claim organization
receive supplemental benefits (discussed later). Health Canada also
provides primary care services in remote and isolated areas when
the provincial or territorial government cannot meet these needs.
Children of First Nations parents receive health coverage for a year
after which time the parents must apply for the child’s Indian status.
A primary source of information for Canadians, Health Canada
conducts research projects and provides feedback on policy
development. The ministry interacts with other nations and with the
WHO to keep Canadians up to date on health concerns around the
world. In conjunction with the WHO, Health Canada issues travel
alerts and warnings for areas where health issues are cause for
concern. The ministry also produces and implements national
campaigns for health promotion and disease prevention, such as
active lifestyle and anti-smoking campaigns.
Health canada organization and structure
Ministry Level
The prime minister of Canada appoints an elected representative to
head Health Canada as minister of health, a position that the prime
minister can reassign at any time during the tenure of the party in
power. The minister of health is responsible for “maintaining and
improving the health of Canadians” (Health Canada, 2013),
including overseeing more than 20 health-related laws and
associated regulations. On occasion, the federal minister of health
may also be responsible for other portfolios.
Responsibilities of the minister of health include:
Thinking it Through
Officials of Health Canada are unelected employees that may work
under the authority of different governments. They are considered
apolitical and remain in their positions even if a different party
assumes power after an election (e.g., a change from a Liberal to a
Conservative or NDP government).
Departmental Secretariat
An executive office to which other departments report, the
Departmental Secretariat acts as the link between the executive
(appointed) and the political (elected) levels of Health Canada. This
department clarifies, redirects, or responds to communications
received from other divisions of Health Canada addressing requests,
for example, that fall under the Access to Information Act and
Privacy Act.
e-sight glasses.
Source: eSight.
Thinking it Through
A patient tells you that she is taking a number of herbal
medications, including synthetic estrogen preparations and
metabolism boosters. She found on the Internet that these
medications were recommended to combat fatigue and
sluggishness. She believes it is unnecessary to tell her primary care
provider.
Box 2.2
Canadian Institutes of Health Research (CIHR)
Institutes Across Canada.
Aging
Cancer Research
Circulatory and Respiratory Health
Gender and Health
Genetics
Health Services and Policy Research
Human Development, Child and Youth Health
Indigenous Peoples’ Health
Infection and Immunity
Musculoskeletal Health and Arthritis
Neurosciences, Mental Health, and Addiction
Nutrition, Metabolism, and Diabetes
Population and Public Health
Thinking it Through
Billions of dollars are spent annually on research, development, and
clinical trials to test the safety and effectiveness of new drugs. Patent
protection allows 20 years for pharmaceutical firms to make a profit
on drugs they have brought to market. Companies that produce
generic drugs, however, are pushing for a reduction in patent
protection time so they can bring cheaper, generic brands of
patented drugs to the market earlier.
Box 2.3
The World Health Organization: The Six-Point
Agenda.
Health Objectives
Strategic Needs
External Approaches
Source: World Health Organization. (2013). The WHO agenda. Retrieved from
h p://www.un.org/youthenvoy/2013/09/who-world-health-organisation/.
Influenza
Individuals at the WHO responsible for making recommendations
on the formulation of the seasonal flu vaccine, which is used
globally, meet twice a year (in February or March, and September) to
review evidence and make decisions. The WHO makes its annual
recommendations by analyzing information provided through WHO
Global Influenza Surveillance and Response System.
The 2017–2018 flu that swept through Europe and North America
appeared to have epidemic (bordering pandemic) characteristics. It
spread rapidly, with more severe symptoms than usual, and higher
rates of hospitalization and mortality. In the event of an
outbreak/epidemic, the surveillance, containment, and treatment
strategies must follow guidelines determined by regional public
health authorities working collaboratively with other stakeholders
such as physicians, hospitals, or long-term care facilities.
Outbreaks of influenza are recurrent but unpredictable events that
can have serious effects on global and national economies, as well as
on the health of populations. It is the responsibility of the WHO to
monitor the threat of potential global influenza and issue
appropriate alerts based on specific criteria, as outlined in the
WHO’s guidance document, Pandemic Influenza Risk Management
(often just referred to as “Guidance”).
The Guidance put together by health and policy experts
incorporates principles from other strategic initiatives, including
principles from the WHO’s Guidelines for Emergency Risk
Communication, All-Hazards Emergency Risk Management for Health
(ERMH), and from its International Health Regulations (IHR). The
IHR is a legally binding agreement for member states that details
procedures and policies for managing public health threats.
The WHO last revised its pandemic guidelines in 2013,
incorporating lessons learned from the 2009 AH1N1 pandemic.
Changes include the following:
Thinking it Through
Ethical Use of Vaccines
Part of pandemic response must include ethical considerations of
any population group. If an experimental vaccine that was
developed in a laboratory looked promising, would you consider it
to be reasonable to give the vaccine to people during a serious
disease outbreak, in hopes that it would provide immunity even
though human trials were incomplete? Why or why not? If proven
effective, but only a limited number of doses had been produced,
how can a health authority equally and fairly distribute the vaccine?
What criteria would you deem essential in making such a decision?
Summary
2.1 Through its complex and frequently changing hierarchical
structure, Health Canada works to fulfill its mission to make
Canadians among the healthiest populations in the world.
Contrary to the belief of many Canadians, the federal
government has li le legal power over health care in the
provinces and territories. Health Canada plays an
authoritarian role in enforcing compliance with the Canada
Health Act in that it can withhold federal-to-provincial
transfers of funds when a province or territory breaches the
principles and conditions of the Act.
2.2 Health Canada is led by the minister of health, who is
supported by a deputy minister, assistant deputy ministers,
an associate deputy minister, a chief public health officer,
and the Departmental Secretariat. The minister of health is
appointed by Parliament; deputies and assistant deputies are
not. The primary responsibilities of the minister of health
include overseeing other agencies, supervising the collection
and analysis of information carried out under the Statistics
Act, and working collaboratively with the provincial and
territorial governments.
2.3 Health Canada’s internal services include those that provide
generalized services, activities, and resources across the
breadth of the organization. The Minister of Health, the
Deputy and Associate Ministers of Health are at the top of
the organizational framework, followed by numerous
Branches, Directorates, and Agencies forming working both
independently and collaboratively within and outside of the
organization. Branches of Health Canada include the First
Nations and Inuit Health Branch, the Health Products and
Food Branch, the Healthy Environments and Consumer
Safety Branch, and the Communication and Public Affairs
Branch. These branches are responsible for activities more
directly aligned with the public’s health and safety.
2.4 Several autonomous agencies work collaboratively with
Health Canada, reporting directly to the minister of health.
These agencies include the Public Health Agency of Canada
(PHAC), the Canadian Institutes of Health Research (CIHR),
the Hazardous Materials Information Review Commission,
and the Patented Medicine Prices Review Board. The PHAC
plays a significant role in health promotion and disease
prevention initiatives; tracks outbreaks of seasonal flu,
tuberculosis, measles, and other illnesses; and recommends
corrective and preventive measures. The CIHR is
instrumental in directing research projects in over 13 sites
across the country.
2.5 Health Canada is active on an international level, working
with a number of organizations to improve health at both a
national and an international level. The World Health
Organization (WHO), a key player in such initiatives,
provides leadership on health ma ers globally. The WHO
recognizes health threats, such as the H1N1 virus, and
initializes pandemic alerts in response to information
gathered. The Pan-American Health Organization aims to
improve health and living standards in the Americas. The
Organisation for Economic Co-operation and Development
measures the quality of medical care in member countries
and rates health outcomes.
Review questions
1. What are the primary objectives of Health Canada?
2. What general services does Health Canada provide for
Indigenous population groups?
a. Explain what agencies within Health Canada are
also involved with health care.
b. Briefly discuss the benefits provided by the Non-
Insured Health Benefits Program.
3. Explain the primary responsibilities of the minister of health
and the deputy minister of health.
4. What is Jordon’s Principle, and what benefits does this
principle offer Indigenous children?
5. How do the functions and responsibilities of the Institute of
Health Information and the Institute of Health Research
differ?
6. How did Jordon’s Principle come about and who does it most
benefit?
7. Identify two international organizations Health Canada
works with and briefly list their functions.
8. Explain the differences between an epidemic, a pandemic,
and an outbreak.
References
Canadian Institutes of Health Research. Home page.
Retrieved from h p://www.cihr-irsc.gc.ca/e/193.html.
2014.
Canadian Nurses Association. The Canadian Nurse
Practitioner Initiative. Retrieved from h ps://cna-
aiic.ca/en/professional-development/advanced-
nursing-practice/nurse-practitioners/canadian-nurse-
practitioner-initiative. 2018.
Health Canada. Eating well with Canada’s food guide:
First Nations, Inuit, and Métis. Retrieved from
h ps://www.canada.ca/en/health-
canada/services/food-nutrition/reports-
publications/eating-well-canada-food-guide-first-
nations-inuit-metis.html. 2010.
Health Canada. Drugs and health products: Canada
vigilance program—collecting and assessing adverse
reaction reports. Retrieved from h p://www.hc-
sc.gc.ca/dhp-mps/pubs/medeff/_fs-if/2011-cvp-
pcv/index-eng.php. 2011.
Health Canada. About Health Canada: Health
portfolio. Retrieved from h p://www.hc-sc.gc.ca/ahc-
asc/minist/portfolio/index-eng.php. 2013.
Health Canada. (2016a). About Health Canada: About
mission, values, activities. Retrieved from
h p://www.hc-sc.gc.ca/ahc-asc/activit/about-
apropos/index-eng.php.
Health Canada. (2016b). Laboratory testing
recommendations for Zika virus. Retrieved from
h p://healthycanadians.gc.ca/publications/diseases-
conditions-maladies-affections/laboratory-testing-
zika-analyse-laboratoire/index-eng.php
Health Canada. For health professionals: Zika virus
infection. Retrieved from
h ps://www.canada.ca/en/public-
health/services/diseases/zika-virus/health-
professionals-zika-virus.html. 2018.
Health Canada. Canada’s food guide. Retrieved from
h ps://food-guide.canada.ca/en/. 2019.
Organisation for Economic Co-Operation and
Development. Health at a glance 2013: OECD
indicators. Retrieved from
h p://www.oecd.org/health/health-systems/health-
at-a-glance.htm. 2013.
3
The Role of Provincial and Territorial
Governments in Health Care
LEARNING OUTCOMES
KEY TERMS
Copayment
Deductible
Dispensing fee
Drug identification number (DIN)
Enhanced services
Formulary list
Box 3.1
The Constitution Act: A Clarification.
The original British North America Act of 1867 became the Constitution Act
in 1982, when Britain surrendered the power to make Canada’s laws,
including its Constitution. Among other things, the Constitution Act
outlines the division of health care responsibilities.
Primary care refers to “first contact” services to which the public has
direct access. Traditionally a person would go to see a primary care
provider, who for the most part is a family physician or a nurse
practitioner, for medical advice. However, with a multidisciplinary team
approach to primary care that may vary, enabling individuals to contact a
variety of providers for initial treatment (in addition to a physician or
nurse practitioner) ranging from a chiropractor, physiotherapist,
nutritionist, counsellor, or psychologist. Primary care facilities include
your provider’s office/facility, a variety of clinics (walk-in, rapid access,
ambulatory care), and the emergency department. If your primary care
provider cannot manage your health issue and/or feels you need more in
depth, specialized assessments, he or she will refer you to a specialist who
provides secondary care.
Secondary care occurs when a patient is sent to see a specialist (seeking a
consultation), which usually requires a referral (e.g., from a physician,
nurse practitioner, or midwife). The referring physician is required to send
a detailed report about the patient to the specialist, concerning the reason
for the referral, including lab and diagnostic tests. A specialist assists the
primary care practitioner to diagnose a patient’s problem and orders the
appropriate treatment, but the specialist’s involvement is usually short
term. Secondary care may involve admission to a general hospital or
referral to a highly specialized facility, which provides tertiary care.
Highly specialized tertiary care also requires a referral. A cancer centre or
cardiology centre, for example, would provide tertiary care. Other
examples include facilities that specialize in treating burn patients,
neurosurgery, complex mental health, and palliative care. In a tertiary care
se ing, the patient may receive care from the referring specialist or from
another specialist (or both). Once care is considered complete, the patient
may be sent back to the referring specialist, who will then discharge the
patient back to his or her family doctor. Alternatively, the tertiary care
centre itself may refer the patient back to the family doctor.
Finally, quaternary care is an extension of tertiary care and even more
specialized, sometimes involving experimental procedures. Hospitals that
do research (often linked with universities) may provide this level of care.
Case Example 3.4 shows how each level of care works in a practical
scenario.
Box 3.2
Regional Health Authorities: A Definition.
Regional health authorities (RHAs) are autonomous health care
organizations responsible for health care administration in a defined
geographic region within a province or territory. Through appointed or
elected boards of governance, RHAs manage the funding and/or delivery
of community and institutional health care services within their regions.
Source: Ferrell, B., & Coyle, N. (2006). Textbook of palliative nursing. New York: Oxford
University Press.
British Columbia
In British Columbia the Ministry of Health (MOH) works collaboratively
with a provincial health authority, five regional authorities, and First
Nations Health Authority to deliver health care in the province. The MOH
establishes performance and evaluation guidelines for health care delivery
and performance outcomes. The regional health authorities oversee
planning and delivery of care in their geographic areas both assessing and
meeting the needs of the population within their jurisdictions. They are
also responsible for ensuring that programs are properly funded (within a
given budget). Another regional authority, the Provincial Health Services
Authority, collaborates with the five RHAs to implement provincial
programs. The First Nations Health Authority, established in 2013, has
assumed responsibility for delivering culturally sensitive and appropriate
health care programs and services to First Nations people in the province
(formerly overseen by Health Canada’s First Nations Inuit Health Branch
—Pacific Region).
Each RHA has an appointed board and is managed by an executive
team, which participates in decision making at the operational level. The
RHAs also manage community health councils (CHCs), which offer a
variety of services throughout the province, including primary care clinics,
health promotion, addictions services, home care, community mental
health services, and specialized services, such as assistance for new
immigrants, support for new mothers, and youth health drop-in centres.
The range of services each CHC offers reflects the needs of the community
it serves.
Alberta
In 2008, the government of Alberta reduced the nine regional health
authorities to one, a new agency called the Alberta Health Services Board.
The original Alberta Health Services Board was disbanded by the
provincial government (over financial disputes) and reintroduced in 2017.
The board is responsible for the governance of Alberta Health Services
(AHS), working collaboratively with Alberta Health. The board also
assumed responsibility of the Alberta Mental Health Board, the Alberta
Cancer Board, and the Alberta Alcohol and Drug Abuse Commission.
This new governance model continues to strengthen Alberta’s approach
to managing health care services, including surgical access, long-term care,
chronic disease management, addiction and mental health services, and
primary care access. In 2013, in addition to the province’s 42 primary care
networks, AHS introduced the unique concept of family care clinics
(FCCs). FCCs provide direct access to a variety of nonemergency services.
FCCs do not have to be headed by a physician, and individuals can see
any team member without a physician’s referral. These FCCs have
significantly reduced the number of people visiting emergency
departments.
Saskatchewan
Saskatchewan has partnered with an organization called 3sHealth or
Health Services Saskatchewan with the dual purposes of improving health
care services and spending health care dollars more effectively. The
partnership involves all stakeholders (including cancer care) and shares
services where possible, improves access to services, eliminates
unnecessary steps regarding access to and receipt of care, and promotes
other cost saving strategies—based on the LEAN principle (discussed in
Chapter 10). Health also manages payroll services, workplace benefits, and
provincial contracts for goods and services.
In 2017, the government of Saskatchewan dissolved its 12 regional
health authorities (also called health regions) replacing them with one
authority, the Saskatchewan Health Authority. The intent was to
streamline and be er coordinate the delivery of health care and cut costs.
The government estimated that moving to a single health authority would
save the province approximately $9 million per year. Health services
remain unchanged for the most part. The Saskatchewan Health Authority
oversees hospitals, emergency response and ambulance services, long-
term care and home care programs, community health services (including
public health), and mental health and rehabilitation services (Health
Shared Services Saskatchewan, 2014).
The Saskatchewan Cancer Agency plans and implements most of the
cancer services in the province. The agency’s duties include evaluating
and developing guidelines for standards of care, treatment, and health
promotion initiatives.
Manitoba
In 2012, Manitoba’s 11 RHAs were reassigned into five regions: Northern
Health, Prairie Mountain Health, Winnipeg–Churchill Health Region,
Interlake Eastern RHA, and Southern Health. Each is overseen by a board
of directors headed by a chairperson reporting ultimately to the Ministry
of Health. The RHAs assess and prioritize community needs and deliver
hospital care, long-term care, home care, public health services,
rehabilitative services, ambulance services, and laboratory services.
Manitoba also delivers health care services (e.g., medical care, counselling,
and health education) through community health centres, divisions of the
RHAs run by local community boards.
Ontario
In early 2019 the Ontario government implemented sweeping changes to
the provincial health care system. Implementation of the new framework
will be rolled out gradually; to fully understand the magnitude of these
changes, it is important to understand the way in which health care has
been delivered over the past few years.
Previous Framework
In Ontario, the Ministry of Health and Long-Term Care (MOHLTC) is—
and remains—responsible and accountable for publicly funded health care
in the province. Until 2019, 14 corporations called Local Health Integration
Networks (LHIN) were responsible for implementing health care services
for designated regions across Ontario; they were based on a population
health/health promotion approach. These nonprofit organizations
(responsible to and funded by the MOHLTC) operated within the scope of
agreements negotiated with the Ministry. LHIN’s determine, plan, and
provide funding for the health services deemed necessary within, and
specific to the needs of, their designated regions. LHINs have been directly
responsible for hospitals, community support service organizations,
primary care, mental health and addiction agencies, community health
centres, and Aboriginal/Indigenous Health Access Centres, as well long-
term care facilities. In addition, Community Care Access Centres recently
managed a number of services, primarily the organization and delivery of
home and community care; they were also the point of entry for Ontarians
admi ed to long-term care facilities. LHINs allocate their designated
funds (from the Ministry) to pay for approved services.
Restructuring under the Peoples Health Care Act 2019, the Ontario
government has created a “super agency” called Ontario Health. It is
headed by a chief executive officer and a board of directors. The goals of
this restructuring are multiple, including: (1) to provide Ontario residents
with simplified access to and navigation of the health care system and (2)
to promote integrated care, improving connectivity to services, reduce
costs, and improve efficiencies among health care agencies. Under the new
framework, the existing LHINs were dissolved and merged with six other
agencies: Cancer Care Ontario, eHealth Ontario, Trillium Gift of Life
Network, Health Shared Services (supported the LHINs and digital health
platforms throughout the province), Health Quality Ontario (providing
oversite regarding the quality of health care), and HealthForceOntario
Marketing and Recruitment Agency (responsible for determining the
appropriate mix of health providers).
Ultimately, all hospitals, community health services, mental health
agencies, cancer treatment centres, organ donation programs, home care,
and end-of-life care will all be under the direction of Health Ontario. A
number of Ontario Health teams made up of local providers (e.g., a
hospital, home care agencies, and mental health agencies) will provide
coordinated care in specific regions. Ontarians will have one number to
call to initiate access to the services they need. (CBC/Radio Canada, 2019).
Quebec
In Quebec, the Ministère de la Santé et des Services sociaux (MSSS) is
responsible for both health and social services. The MSSS shares these
responsibilities with Quebec’s 18 RHAs—15 health and social services
agencies and three regional associations in northern parts of the province
(the Centre régional de santé et de services sociaux de la Baie-James in the
Nord-du-Québec region, the Nunavik Regional Board of Health and Social
Services in the Nunavik region, and the Cree Board of Health and Social
Services of Baie-James). Responsibilities of the RHAs include hospitals,
long-term care, home care, public health, mental health, rehabilitation,
social services, and laboratory and ambulance services—a more
comprehensive list of responsibilities than those of most other
jurisdictions.
In 2004, 95 local service networks were established across the province
to work under their respective RHAs. These networks provide
comprehensive, accessible health care services to the populations in their
region. At the heart of these local networks lie health and social services
centres, created by merging local community health centres, residential
and long-term care centres, and general and specialized hospital centres.
By constructing service agreements with partners and stakeholders within
the local services networks (e.g., rehabilitation centres, physician groups,
medical clinics, youth protection centres, mental health organizations,
university hospital centres), these centres ensure seamless access to
primary, secondary, and tertiary care and adequate follow-up for the
populations they serve.
New Brunswick
The Department of Health (DOH) in New Brunswick is responsible for all
health care in the province, including overseeing the funding, planning,
and delivery of selected health care services through the province’s two
regional health authorities (Vitalité Health Network and Horizon Health
Network). A board of directors oversees the operation of each RHA. These
RHAs are responsible for hospital services, community health centre
services, extramural services, most public health services, mental health
and addictions services, and some tertiary services such as cardiac care
and neurosurgery. The DOH retains responsibilities for other services such
as long-term care and Ambulance New Brunswick. The government has
engaged with a public company, Facilicorp NB, to assume responsibilities
for certain nonclinical services including the management of their
information systems.
Nova Scotia
In 2015, the nine previous district health authorities were merged into one
—the Nova Scotia Health Authority (NSHA). The NSHA works with the
Izaak Walton Killam (IWK) Health Centre, an independent women’s and
children’s tertiary care hospital, to plan and deliver primary care,
community health, and acute care. The new single authority is also
responsible for Nova Scotia’s Cancer Care Program.
Northern Regions
Sca ered populations and great distances between centres in the northern
regions of Canada present unique and complex challenges in the delivery
of health care. This vast area comprises of the Northwest Territories,
Nunavut, Yukon, and the northern regions of other provinces, particularly
British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, and Quebec.
Technological advances (e.g., electronic health records, Telehealth, video
links to large health centres) have contributed to significant improvements
in the quality and accessibility of health care; however, care in the North
remains woefully inadequate. Frequently, individuals must be air-lifted to
a regional centre, such as Calgary, Edmonton, Winnipeg, or Sioux
Lookout, to receive treatment that cannot be provided within the
community.
Nurses play a significant role in delivering health care in Canada’s
North. There are over 600 Indigenous communities alone, serviced by over
70 community care/health centres (sometimes referred to as nursing
stations), and nearly 200 regional health centres. Nurses, more often than
not, are the first point of contact for health care in the North. They are
employed by the federal government, or through a transfer agreement in
communities that assume responsibility for their own health care by the
band council.
The federal government funds much of the health care for northern
Inuit, Métis, and First Nations populations.
Health and health care services in Canada’s North are discussed further
in Chapter 10.
Northwest Territories
In 2016, six of the Health and Social Services Authorities were merged into
one body—the Northwest Territories Health and Social Services Authority.
The overriding goal was to improve the coordination and delivery of
health services with input from residents in the territory. There are two
remaining health authorities. The Hay River Health and Social Services
Authority will continue to deliver care in its jurisdiction with its own
management board whereas the Tlicho Community Services Agency will
deliver care under the Hospital Insurance and Health and Social Services Act.
As with other provinces and territories, the focus for care is on early
child development, chronic diseases, mental health, continuing care,
addiction, and child and family services.
Yukon
The vast territory of the Yukon consists of fewer people than most
midsized towns elsewhere in Canada, with a population of approximately
38 641. This population is expected to grow to 43 000 by 2025. By that time,
it is estimated that 18% of the population will be 65 years of age and older,
while those under 25 will decrease to 25%. The majority of the Yukon’s
population (75%) lives in Whitehorse and the surrounding area. The
biggest challenge is providing health care to the rest of the surrounding
population.
The territory does not have RHAs or similar organizations. The
Department of Health and Social Services (DHSS) manages and delivers
all components of health care through the following divisions: Health
Services, Social Services, Continuing Care, and Corporate Services. The
Health Services division is responsible for community nursing and
community health programs, including the community health centres,
which deliver frontline care and are managed primarily by nurses. The
Continuing Care branch oversees residential and home care in addition to
day care and palliative care programs. The territory has three hospitals,
managed by the Yukon Hospital Association (Yukon Health and Social
Services, 2015).
Nunavut
Nunavut spans one-fifth of Canada’s land mass and has 25 communities
spread across three regions—Baffin, Kivalliq, and Kitikmeot.
Approximately 85% of the territory’s population of roughly 32 000 people
are Inuit. In Nunavut, the Department of Health is responsible for the
delivery of health care as well as policy development and legislation
governing the health care system. As with the other northern regions,
primary care is provided by nurses, nurse practitioners, and visiting
physicians—with widespread use of videoconferencing. Retaining full-
time nurses is an ongoing problem in this region for several reasons,
including geographic and social isolation, and at times a lack of
employment for spouses. Nunavut has approximately 22 community
health centres and three regional health centres: Cambridge Bay, Rankin
Inlet, and the Qikiqtani General Hospital in Iqaluit. The centres in
Cambridge Bay and Rankin Inlet have the capacity to keep patients
overnight. Iqaluit has a family practice clinic and is the only hospital in
Nunavut. O awa is the main referral centre. Health care funding is
centrally managed and distributed, with a significant portion of expenses
going toward medical travel and out-of-territory treatments, as a result of
shortfalls in infrastructure such as diagnostic and service capabilities.
Who pays for health care? Provincial/territorial
roles
Each province and territory has a method (e.g., premiums, payroll tax,
general revenues) of financing health care services not covered by federal
funding. Private and volunteer organizations provide significant revenue
for specific services or hospitals. For example, when a community hospital
builds a new wing, a government grant usually covers part of the expense,
while volunteer groups and municipal governments frequently make up
the balance. A formal building campaign, often launched by the hospital
undergoing the expansion, provides a conduit for donations.
Payroll Tax
Some jurisdictions, including Manitoba, Ontario, Quebec, and
Newfoundland and Labrador, levy a payroll tax (Normandin Beaudry,
2012), a tax collected from employers that specifically raises funds for
health care that may extend to education and social services. This is also
referred to as a dedicated tax. The amount paid depends on many factors.
In Newfoundland and Labrador a 2% tax is payable by employers whose
annual remuneration is over a predetermined exemption threshold
(explained by the government of Newfoundland and Labrador as the total
remuneration paid by an employer less its allocated deduction).
Employers with a payroll below a certain amount may be exempt; others
may pay a reduced amount based on their salary or wage payout. Note
that, in Ontario, this tax is in addition to health care premiums paid by
residents.
Thinking it Through
Some provinces charge premiums for health care; others do not.
Box 3.3
Reciprocal Agreement.
The reciprocal agreement supports the principle of health insurance
portability (see Chapter 2) among the provinces and territories. Through
the agreement, a person’s province of origin will pay for required health
services in another province or territory at the rates imposed by the host
province. This interprovincial agreement is not mandatory. For example,
Quebec has not signed this agreement.
As a result of this agreement, Canadians, for the most part, will not face
point-of-service charges for medically required hospital and physician
services when they travel within Canada. In most cases, a person can
receive care in a host province by simply presenting his or her health card,
and the patient’s province of origin will pay the host province for services
delivery.
Source: Health Canada. (2007). Health care system—Canada Health Act.
Thinking it Through
The Arrival of a Syrian Family
Kadan, Selda, and their daughter, Milana, have just arrived in Canada
from Syria, sponsored by a church group. They have been granted
permanent residency status upon landing in the country, which usually
means they are immediately eligible for health care under the Interim
Federal Health Care program (see Chapter 2). However, they still must
apply for a provincial/territorial coverage upon arrival to obtain a health
card following proper protocol and with proper documentation. When
they apply they will be given a temporary paper health card until the
official provincial/territorial card arrives in the mail.
Most provinces and territories also offer limited vision and dental care.
Milana is in good health but badly in need of dental work, Selda lost her
glasses 6 months earlier, and Kadan has been complaining of headaches.
The family will need assistance navigating the health care system,
coordinating appointments, filling out documents, with the help of an
interpreter.
Considering the process in your jurisdiction:
1. What are the documents they will need to apply for health care in
your jurisdiction?
2. What are the limits to vision and dental coverage (if any) in your
province/territory? What provider would Kadan see regarding his
headaches? If the services of a specialist were required, would that
be covered?
3. How can you in your professional role assist this family with their
health care needs?
Health Cards
Once an application is approved, the Ministry or Department of Health
issues the applicant a health card, identified by a number for the province
or territory in which he or she resides. Some jurisdictions assign a number
to a whole family, and later when the children reach a certain age, issue
the children an individual health number. Other jurisdictions issue a
personal health number to each person. In Ontario, for example, babies are
issued an individual health number at birth.
Box 3.4
Private Clinics: Concerns.
Significant concerns exist across Canada about private clinics. At the
forefront lies the worry that the availability of private clinics will lengthen
wait times for those using the public system because private clinics use
the services of physicians and other health care providers who also work
in the public system. Some believe that doctors’ time in the public system
will be lessened; others argue that physicians working in the private
sector do so on their own time, thus not interfering with services offered
in the public system. For example, an orthopedic surgeon may have only
2 days of operating room time available to him or her, leaving 3 days a
week during which he or she cannot perform surgical procedures. On
such days, the surgeon can see patients in a private clinic, perhaps doing
knee or hip replacements, and conversely, shorten the line in the public
system.
Another concern is that patients paying for enhanced services will
unfairly move to the top of wait lists because of the additional revenue for
the clinic. For example, in many jurisdictions, a patient having a hip
replacement in the public system will receive offers of “upgrades” to a
superior product for the replacement part used in the procedure (e.g.,
titanium), which generates revenue for the hospital. Some claim that
people purchasing such upgrades move up the list.
Bundled services, some claim, provide another method by which
individuals can jump the queue. For example, a clinic performing cataract
surgery can “bundle” an uninsured laser surgery with the insured
cataract surgery. The patient paying for the laser portion of the procedure
could be bumped up the list, while someone wanting cataract surgery
continues to wait. More often than not, the enhanced or bundled service
will occur at a private clinic, having no impact on the corresponding
public service.
Private clinics charge substantial fees to individuals using their services
for nonmedically necessary procedures. A growing trend, particularly
within the past 5 years, has seen physicians and specialists pooling their
services to offer routine and specialized care via “health packages.” Such
groups (e.g., the Copeman Healthcare Centres in Vancouver, Calgary, and
Edmonton) charge an enrollment fee and an annual membership fee. In
return for fairly steep fees ($29 000/year for the “elite” program at
Copeman), patients receive the guarantee of prompt access to an
impressive team of health care providers, including family doctors,
dietitians, psychologists, and specialists, along with an array of other
services. Fees are generally tax deductible, and many of the services are
covered by third-party insurance. Critics of this type of private health care
point out that these fees are well out of reach of the average Canadian
family.
To what extent a two-tier system will develop in Canada is anyone’s
guess. The availability of private clinics and services suggests that, in one
form or another, a two-tiered system will continue to exist.
Hospital Services
In the hospital se ing insured services for inpatients include standard
hospital accommodation, meals, certain medications (in some regions,
patients are asked to bring their own medications), operating room and
delivery room services, anaesthetic facilities, diagnostic and laboratory
services, routine medical and surgical supplies used for hospitalized
patients, routine nursing care, and certain rehabilitative services (e.g.,
physiotherapy). Provincial and territorial plans do not cover private
nursing care unless ordered by a doctor, at which point the care becomes
medically necessary and is covered. Note that the cost of a private room
may be covered by the provincial or territorial plan under some
circumstances (e.g., for infection control, isolation purposes, or
compassionate reasons).
Insured outpatient hospital services include emergency treatment, day
surgery, and diagnostic and radiological procedures at a hospital or at
private diagnostic centres (e.g., outpatient cancer centre, orthopedic clinic).
In addition, most jurisdictions insure physiotherapy, occupational
therapy, and respiratory therapy services for a limited period if deemed
medically necessary.
Medical Services
Under the Canada Health Act, medically necessary care provided by a
medical doctor (i.e., family doctor or specialist) is an insured service, with
some conditions. In Ontario, for example, a person can claim coverage for
only one visit to a medical doctor per day unless the physician submits the
claim for special review. What is deemed medically necessary may vary a
li le across the country but is fairly standard.
Rules also govern insured services provided by a specialist. For instance,
in most provinces and territories, a doctor must refer a patient to a
specialist; the patient may see the specialist again for the same problem
within a calendar year. After that, or for a new symptom or complaint, the
family doctor must provide another referral. In most jurisdictions, when a
patient requests the opinion of a second specialist, the provincial or
territorial plan will pay for that visit if the family doctor provides another
referral request. After receiving a second opinion, however, the patient
would usually have to pay for further consultations even if referred by his
or her family doctor.
Each province and territory generates its own list of insured services,
which is reviewed periodically by the Ministry or Department of Health
and the Province’s or territory’s medical association. At this time, some
services may be delisted, and others added. Since “medically necessary” is
subjective, these services vary from one jurisdiction to another. For
example, having wax removed from one’s ear is insured in British
Columbia, but not in Nova Scotia (although it is covered for children).
Ontario’s provincial plan no longer covers what used to be called an
annual checkup, but now recommends a less extensive assessment, called
a periodic health visit, limited to one visit per patient per 12-month period.
British Columbia and several other jurisdictions do not cover an annual
health exam; rather, the extent of an examination is complaint-driven.
Patients can request a complete physical but must pay for it themselves.
Physicians, especially in primary care groups, may choose to offer a
selection of services to their patients that are deemed not medically
necessary by their provincial or territorial health care plan. Because
primary care groups offer team-based care, these services can include
dietary counselling, podiatry services, grief counselling, access to
psychotherapy sessions, and a range of preventive care services.
For other noninsured services (e.g., third party physical examinations
required for a work-related driver’s licence), physicians may bill patients
directly, or they may bill a third party—an insurance company, the
Workplace Safety Insurance Board (WSIB), or an employer or other payer.
The amount a doctor charges for uninsured services depends on
guidelines set out by the governing medical association (Box 3.5).
Box 3.5
Uninsured (Chargeable) Versus Insured Physician
Services.
Note: Services that are uninsured vary; many primary care organizations or groups
offer ‘bundled’ services, which may include travel advice, counselling (e.g., smoking
cessation, diatetic, and grief), prescription renewals, and telephone advice. These
groups also may offer wart clinics (wart removal has historically been an uninsured
procedure). Third party physical assessments, certain vaccinations, and completion
of most insurance forms often remains uninsured in primary care groups.
Thinking it Through
Primary care providers (as well as specialists) are required to inform
patients of the price of any procedure, assessment, or treatment not
covered by their provincial or territorial plan before any uninsured
service is carried out. Patients typically pay out-of-pocket each time an
uninsured service is performed. Some doctors however, offer patients an
alternative called a block payment plan, whereby patients pay a flat fee for
selected (uninsured) services over a predetermined time frame usually
not less than 3 months. Examples of such services include medicals for
employment or camp, return-to-school or return-to-work notes and travel
immunizations/shots. The physician must not refuse services, and must
not show preferential treatment to patients who pay block fees.
Ambulance Services
In most jurisdictions, land and air ambulance services are either under
regional management, and costs are shared with the provincial or
territorial government, or these services are delivered privately through
performance-based contracts. Because ambulance services are not
addressed in the Canada Health Act, provinces and territories can establish
their own guidelines, including fee schedules for these services.
People using an ambulance even for medically necessary reasons may
be responsible for a copayment (Case Example 3.8). However, fees are not
usually charged for transportation between hospitals—whether the
destination hospital is within a short distance, in another part of the
province, in another province altogether, or outside of the country—as
long as the transfer is for medically necessary reasons (Case Example 3.9).
Interfacility transfers (e.g., from one nursing home to another) usually
require a copayment. Most jurisdictions either reduce or eliminate the
copayment for low-income individuals and families.
Copayments (also sometimes called user fees or service fees) vary, and all
jurisdictions exempt some people from them, including individuals in
long-term care homes or on provincial or territorial subsidized programs.
Ambulance services are often used as a mode of transport, which is misuse
of the service. In such cases the “user” is charged the full amount of the
ambulance transfer.
• Home care helps individuals with basic personal care, meals, and
household maintenance, allowing them to remain at home even
once they find caring for themselves difficult.
• Adult day programs provide community day activities as well as
respite care and in-home support to individuals with disabilities.
• Respite care, which allows nonprofessional caregivers some relief
from caring for disabled family members, is often offered in long-
term care facilities or the equivalent for a designated time frame.
• Assisted living accommodation helps to keep a person in his or her
home by providing individualized support and care as required.
• Group homes allow persons with disabilities to live in an
environment that provides supervision and assistance.
• Hospice care is provided in a home-like se ing for those unable or
unwilling to die at home. Individuals receive nursing and medical
care, pain management, counselling, and other supportive care
needed while dying. When a community or region builds a
hospice, funding is often from multiple sources ranging from
community resources to municipal and provincial governments.
• Palliative care provides care, medication, and some medical
supplies for individuals dying at home.
• Medical Assistance in Dying is in accordance with the law, and
overseen and paid for by provincial and territorial governments
(see Chapter 8).
Assistive Devices and Medical Products
Those in need of but unable to afford health care products and assistive
devices—mobility devices (e.g., wheelchairs, walkers, motorized carts),
prosthetic devices (e.g., postmastectomy products, artificial limbs), bathing
and toileting aids, and hospital beds and accessories—can receive
supplemental coverage; however, the coverage for such items varies across
Canada. In most jurisdictions, patients able to pay are responsible for a
portion of the cost of selected assistive devices. For those that cannot pay,
the cost is absorbed by the provincial plan. For example, Alberta offers
two income-based programs: the Alberta Aids to Daily Living (AADL) and
the Dental Assistance for Seniors programs. The AADL offers financial
support to eligible Albertans with a long-term disability, chronic illness, or
terminal illness for the purchase of medical equipment and supplies. The
dental assistance program provides low- and moderate-income seniors
with a maximum value for eligible dental procedures every 5 years.
Drug Plans
Medications consume a huge portion of the health care dollars spent
across Canada, second only to hospital spending. The immensity of this
expenditure stems, in part, from the use of newer, more expensive drugs
and an aging population with chronic diseases and multiple health
problems, who are prescribed an astonishing array of medications. More
detail about drug costing is discussed in Chapter 4.
All provinces and territories across Canada offer publicly funded
prescription drug programs (often called PharmaCare) to individuals on
social assistance, anyone who must make payments that are
disproportionate to their income, and Canadians over the age of 65. Nova
Scotia and Quebec charge income-based premiums for the PharmaCare
plan for seniors; New Brunswick, Quebec, and Alberta offer public
PharmaCare plans to those under 65, and also charge income-based
premiums. In Quebec enrolling in a drug plan is mandatory, thus all
residents of the province have drug coverage. As previously mentioned,
Ontario introduced coverage for those under the age of 25 in 2017. In 2018
the Ontario government places some restrictions on this program affecting
individuals with private coverage (Clement, Soril, Emery, et al., 2016).
As discussed previously, an estimated 60–70% of working Canadians
have some type private or employer-sponsored insurance plans with drug
benefits. However, many jobs available now are contract positions; in
addition, a number of younger Canadians are changing jobs more
frequently than in the past. These trends mean that the security of having
employer-subsidized benefits are limited or nonexistent, leaving more
Canadians in the position of having to buy private health insurance—or
rely on the public system.
Most private drug plans are fairly comprehensive, but public plans
insure only certain medications. Both publicly funded drug benefit
packages (discussed later) and private insurance plans have copayments
or deductibles (usually percentage based) that beneficiaries pay,
depending on their income and drug costs. Private insurance plans also
require beneficiaries to pay dispensing fees themselves. For individuals on
a public drug plan, the dispensing fee is either calculated as a percentage
of the prescription cost or set at a flat rate, depending on the plan.
To qualify for provincial or territorial drug benefits, an individual must
first apply for assistance. Primary care providers and sometimes
pharmacists can assist an individual to navigate their way to the
appropriate organization where they can get more information and/or fill
out an application. Most provinces/territories also provide that
information online. As a rule, jurisdictions require the family or individual
to pay a predetermined deductible for prescription drugs. Once the
deductible is reached, the public plan will pay a percentage of the
beneficiary’s eligible drug costs. Some jurisdictions also set a maximum
amount, or a “cap” that the family or person must pay, after which point,
the plan will cover 100% of the drug costs.
Some plans (both private and public) will cover only drugs prescribed
from a formulary list. Formulary lists, although they include hundreds of
drugs, are limited, containing for the most part, cheaper, generic versions
of common drugs. Some brand-name drugs may be covered, but only if
there is not a less expensive alternative. Combination drugs and time
release drugs for example, are more expensive. Most “lifestyle drugs” are
not covered such as drugs used for erectile dysfunction (e.g., Viagra),
drugs to treat obesity, to prevent hair loss, and also cosmetic drugs (e.g.,
Botox). Some antibiotics (e.g., Avelox) and inhalers used for asthma (e.g.,
Symbicort) are excluded. The general thought is there are cheaper drugs
available that will be effective. However, most plans will cover a
nonformulary drug if the generic drug does not produce the desired
therapeutic effect or causes adverse effects (Case Example 3.10). Providers
prescribing the drug must seek approval to prescribe a nonformulary
drug. Nonformulary drugs also are likely to include high-cost drugs or
drugs with a high potential for misuse. Many private insurance plans offer
an “open access” plan that will insure all prescription medications
approved by Health Canada that are prescribed on an outpatient basis.
Drugs are constantly being added to the formulary list, including,
rivaroxaban (Xarelto) and dabigatran (Pradaxa), which are new-generation
drugs used to reduce clo ing times. Unlike previously preferred
anticoagulants, these drugs do not require routine laboratory monitoring.
Each formulary includes a limited use (LU) list, which lists drugs
deemed unsuitable or too expensive to be on the formulary list. These
drugs may, however, have therapeutic benefits in special circumstances—
for example, an antibiotic that can treat resistant bacteria.
Some drugs are not on either the formulary or the LU list. The
prescribing provider must seek special permission to have these drugs
covered by a publicly funded drug benefit plan. Some biologics that are
used to treat inflammatory diseases (e.g., inflammatory bowel disease and
rheumatoid arthritis) require special permission. In 2016, ten provinces
spent a staggering $8.8 billion on therapeutic drugs. Drugs used to treat
the following conditions (in no particular order) were the costliest: cancer
treatment (neoplastic agents), antineovascularization drugs (e.g., for the
wet form of macular degeneration), antiinflammatory drugs, antivirals (for
hepatitis C), and protein pump inhibitors (for gastric problems).
Thinking it Through
A growing number of Canadians cannot afford the out-of-pocket cost of
some prescription drugs—many choosing not to fill prescriptions. Some
biologics and chemotherapeutic agents for example, may not be covered
by public or private insurance. Note that what drugs are covered varies
with each jurisdiction. Drugs for some individuals cost up $100 000 per
year for one person, and the person may be required to take the
medication for the rest of his or her life. All jurisdictions are already
cu ing back on services resulting in long wait times for access to
providers, diagnostic tests, and surgery.
1. Do you think the public system should cover the cost of drugs,
including those that are extremely costly?
2. What provisions are available in your jurisdiction to assist
individuals with catastrophic drug expenses? Are there individuals
excluded from provincial/territorial assistance?
3. Would you agree to a national drug plan if such a plan meant longer
waits and limited access to other services for all Canadians?
Summary
3.1 The Canada Health Act oversees 13 separate health insurance
programs—one for each province and territory. Adherence to the
principles and conditions of the Canada Health Act binds the
provinces and territories to a set of predetermined obligations for
health care delivery. Otherwise, each jurisdiction is free to deliver
and pay for services deemed appropriate (e.g., assistive devices,
long-term care).
3.2 Jurisdictions delivering health care through regional health
organizations/authorities do so using a decentralized framework.
RHAs assess the type and mix of services appropriate for a
geographic area and support services that meet the needs of that
region (e.g., the region may have an older population and need
more long-term care and community services; another may need
more primary care services). Some jurisdictions (Saskatchewan and
the Northwest Territories) have moved towards a single health
authority to save money and reduce the “red tape” associated with
regionalization.
3.3 Payment for health care services is provided in part by the Federal
Government. The largest cash transfer is the Canada Health
transfer. A blend of taxes at the provincial and territorial level
makes up the rest. Two provinces (British Columbia and Ontario)
require their residents to pay health care premiums. Volunteer
organizations across the country contribute significantly to
covering the cost of some services and equipment.
3.4 All those eligible for health care in each jurisdiction receive
hospital and medical care deemed medically necessary. Dental care
is included only if it is dental surgery done in a hospital (then
regarded as medically necessary surgery). Health care that is
medically necessary is somewhat subjective, although most
insured services are similar across Canada. For newcomers to
Canada and individuals moving from one jurisdiction to another,
wait times (usually no more than 3 months) or other criteria apply.
3.5 Spending on medications is second only to hospital expenditures.
All jurisdictions have a drug plan for individuals who meet
specified criteria—for example, those receiving financial assistance,
those with drug costs disproportionate to their income, disabled
persons, and older adults. Almost everyone, including those with
private drug insurance, must pay a deductible for prescribed
medications.
Review questions
1. How would you respond if someone asked you if Canada had a
national health care plan?
2. What are the differences among primary, secondary, tertiary, and
quaternary care? Give an example of each.
a. Identify a secondary, tertiary, and a quaternary care
facility in your region.
3. What were the four common objectives for adopting a regionalized
approach to health care?
a. Why are some jurisdictions moving back to a central
health authority framework?
b. Does your province or territory use a regionalized
approach to health care delivery, or does it have a single
health authority? Is the adopted approach effective?
Why or why not?
4. What happens if a primary care provider prescribes a medication
for a patient on a subsidized provincial/territorial drug plan and
that drug is not listed on the provincial/territorial formulary of
available drugs?
5. Does charging health care premiums contravene the principles of
the Canada Health Act? Why or why not?
6. What is the purpose of the 3-month wait period in most provinces
before a person can become eligible for health care, and who is
exempt? Explain your answer.
7. What is the purpose of the reciprocal agreement and how does it
benefit Canadians?
8. What types of private health care are available in your jurisdiction?
a. Are their policies and procedures compliant with the
principles of the Canada Health Act?
b. Do you feel that a “two-tiered” health care system could
work in Canada without compromising our universal
health care plan? What would be the benefits and
drawbacks?
9. Assume two new families have arrived in your community from
another country, both granted the status of permanent residents.
One family is sponsored by a private group, the other by the
Government of Canada. Outline the steps each family will have to
take to obtain health insurance and find a family doctor. What
other challenges might these families face? What resources are
available in your community to assist the family that is
government sponsored? Consider language barriers,
transportation, supplemental health care (if required), and cultural
sensitivities.
References
CBC/Radio-Canada. (2019). Interview on Metro Morning with
Ontario Health Minister Christine Ellio . Retrieved from
h ps://www.cbc.ca/news/canada/toronto/ontario-health-
minister-legislation-super-agency-jobs-agency-
consolidation-1.5035203 and
h ps://www.cbc.ca/news/canada/toronto/doug-ford-
ontario-health-super-agency-lhin-cancer-care-1.5032830.
Clement F., Soril L., Emery H., et al. Canadian publicly
funded drug plans, expenditures, and an overview of
patient impacts. Retrieved from
www.health.alberta.ca/documents/Health-Spending-
PubliclyFundedDrugPlans-2016.pdf. 2016.
Health Shared Services Saskatchewan (3sHealth). Corporate
profile. Retrieved from www.3shealth.ca/about-
3shealth/corporate-profile. 2014.
Husni S., Khan Z., MacMillan R., et al. Canada should not
allow two-tiered practicing for medically-necessary services
[web log comment]. Retrieved from
h ps://www.ivey.uwo.ca/healthinnovation/blog/2017/7/ca
nada-should-not-allow-two-tiered-practicing-for-
medically-necessary-services/. 2017.
Ontario Ministry of Finance. Ontario health premium.
Retrieved from h p://www.fin.gov.on.ca/en/tax/health-
premium/. 2014.
Normandin Beaudry. Health insurance premiums and tax.
Retrieved from h p://www.normandin-
beaudry.ca/userfiles/file/Aide-memoire-
2012_Quickfacts_2012_EN.pdf. 2012.
Yukon Health and Social Services. Yukon Health Status
Report 2015: Focus on Substance Use. Retrieved from
www.hss.gov.yk.ca/pdf/health_status_report_2015.pdf.
2015.
4
The Dollars and “Sense” of Health Care
Funding
LEARNING OUTCOMES
KEY TERMS
Active ingredients
Alternate level of care (ALC)
Capitation-based funding
Laparoscopic surgery
Nonprofit organization (NPO)
Positron emission tomography (PET) scanner
Publicly funded health care
Rationalization of services
Renal dialysis
Residential care
Box 4.1
Equalization Payments Embedded in the Canadian
Constitution.
Parliament and the Government of Canada are commi ed to the principle
of making equalization payments to ensure that provincial governments
have sufficient revenues to provide reasonably comparable levels of
public services at reasonably comparable levels of taxation.
Source: Constitution Act, 1982, being Schedule B to the Canada Act 1982 (UK), ss. 36(2).
A needy jurisdiction will receive the difference between its fiscal capacity
(i.e., its ability to generate income) and the 10-province standard (i.e., the
national average). Without equalization payments, these provinces and
territories would have to raise their taxes significantly to generate revenue.
In 2018–2019 equalization payments to these provinces (in millions of
dollars) were: New Brunswick $1874, Prince Edward Island $419, Nova
Scotia $1933, Ontario $963, Quebec $11,732, and Manitoba $2037. BC,
Alberta, Saskatchewan, and Newfoundland and Labrador did not receive
equalization payments. The provinces and territories are free to determine
how they will spend their equalization payments; many use this money, at
least in part, for health care.
Table 4.1
Provincial and Territorial Health Spending per Capita: 2017
(Estimated).
Many different types of health care facilities exist, including general and
acute care facilities, nursing homes, chronic care facilities, rehabilitation
centres, and psychiatric hospitals. All are publicly funded, in part or in
whole. Some hospitals treat certain conditions (e.g., Princess Margaret
Hospital in Toronto specializes in cancer treatment), or specific age groups
(e.g., Vancouver’s B.C. Children’s Hospital). Other facilities (e.g., long-
term care facilities) may be covered only in part by provincial or territorial
insurance, in which case, patients pay a portion of the services they use.
Psychiatric hospitals, and also the services of psychiatrists, are fully
covered in all provinces.
Problems that have faced hospitals, communities, and individuals over
the past few years include cuts to services, reductions in hospital beds,
closures or merging of hospitals, rationalization of services (i.e., improving
efficiency by relegating certain types of care to one facility—pediatrics, for
example), insufficient and demoralized staff, and long wait lists for
surgery, related tests, and admission to hospitals. The following sections
will examine how hospitals are funded, how they operate, why
operational costs are high, and what is being done to lower costs.
Thinking it Through
Not realizing that they pay for health care services with their tax dollars,
many Canadians believe health care is free, leading to misuse and abuse
of the system.
1. If people were given a receipt showing the cost of each doctor’s visit,
hospital stay, and services received, do you think they might use
health care services more prudently?
2. Do you think that lack of awareness of the costs of services
contributes to the a itude that health care is free?
3. Two provinces require health care premiums for services. Do you
think these extra charges void the concept that health care is free?
The Cost of Hospital Care
Hospitals offer diagnostic tests, treatment, and both inpatient and
outpatient (also referred to as ambulatory) care. Patients admi ed to
hospital usually have serious illnesses and diseases in an acute phase,
which cannot be managed outside of the hospital se ing. In outpatient or
ambulatory care, patients are admi ed to hospital, but not for an
overnight stay. These visits can include diagnostic services, clinic care,
outpatient surgery, and emergency department visits. Many services will
include a physician’s services and/or a consultation (usually with a
specialist), but these costs are usually counted separately from the hospital
component of care.
In 2016, the total amount of money (public) spent on the hospital sector
was an estimated $65 billion. This represents the largest financial output of
any other health care spending category, with the cost of patient care
being among the highest cost drivers (CIHI, 2018b). As a result, hospitals
are under significant pressure to operate as efficiently and cost effectively
as possible—not an easy task. It can also generate concern among
Canadians, especially when they experience wait times, and in many
cases, actual or perceived deficiencies in care, but are unaware of the
financial parameters that a hospital must function within.
Costing Details
In 2015, the average cost of a hospital stay ranged from approximately
$8000 in the Yukon Territory and Alberta, just over $6000 in British
Columbia and Nova Scotia, to a low of $5300 in Ontario and New
Brunswick. This averages to a cost per hospital stay of about $1871 per
person. The average costs are affected by the cost variables mentioned
above and the hospital’s specialty. The largest cost drivers are hospital
salaries (excluding physicians’ services), which comprise about 72% of
total costs, and drugs comprising 16.4% of total costs (CIHI, 2017e).
Physicians’ services are excluded from hospital-based salaries because
they are typically paid directly by provincial/territorial medical plans.
There are some exceptions, for example physicians hired by a hospital and
who are paid a salary (either full time or on contract) for specific services.
However, when overall hospital expenses paid by public plans are
calculated, physicians’ services account for about 13.4% of the total annual
estimated amount.
In 2015, Canadians spent almost $65 billion on the hospital sector—the
largest amount spent in any health category. When grouped by general
categories, the most expensive hospitalizations were for cardiovascular
conditions (of interest, a heart/lung transplant is currently the most
expensive at $119,989), followed by mental health disorders, diseases of
the digestive system, and then diseases of the respiratory system.
However, when broken down by diagnosis, diseases of the respiratory
system (i.e., COPD, followed by pneumonia) impose the greatest cost to
hospitals. Hip and knee replacements were the costliest in terms of
hospitalization for interventions, although this is changing (CIHI, 2015). A
new technique, called the anterior approach to hip replacement surgery, is
less invasive, and is done as day surgery. There are fewer muscles at the
front of the hip, so instead of cu ing through them, the surgeon separates
them reducing trauma, and recovery time. Pregnancy and childbirth, the
leading cause of hospital admissions for women of childbearing age, cost
$1000 per person on average, although the cost varies with the nature of
the delivery—an uncomplicated vaginal delivery costs just under $828,
whereas a Caesarean section costs $1270 (CIHI, 2014).
The majority of Canadians remain unaware of how much the
government pays for various procedures. Table 4.2 provides a list of the
costs of some of the more common procedures and conditions for which
individuals are admi ed to hospital. Imagine having to pay to have a
baby, and then your two-year-old needing admission to the hospital for
croup, and your dependent father needing a hip replacement due to a fall.
How would you handle the costs if you had to pay out of pocket?
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.
Source: Canadian Institute for Health Information. (2015). Patient cost estimator.
Retrieved from h ps://www.cihi.ca/en/patient-cost-estimator.
Cost-Reduction Strategies
As mentioned, hospitals use a variety of methods to reduce their overall
costs. The most commonly applied strategies include decreasing patients’
length of stay and rationalizing services.
Length of Stay
The longer a patient stays in the hospital, the higher the cost, detracting
from the hospital’s operational budget. Therefore decreasing the length of
hospital stays is an important way to reduce costs and make beds available
for new admissions. The province or territory determines the cost of an
insured bed to a hospital (paid for out of the allo ed budget) by estimating
the services required by the person occupying the bed. For example, a
patient in an acute care bed recovering from cardiac bypass surgery would
be deemed more expensive than one recovering from an appendectomy.
Interestingly, the use of semi-private and private rooms generates income
for a hospital. More income is generated if a patient upgrades his or her
accommodation from standard accommodation to semiprivate or private
(Case Example 4.1).
Same-Day Admissions
In the past, individuals scheduled for major surgery were admi ed 1 or 2
days prior to their operation for tests and preop preparation, which
consisted of a medical history, a physical, bowel cleansing, shave if
needed, preoperative instruction, and nigh ime sedation to ensure a
sound sleep.
Today, for many surgeries, this preparation is done on an outpatient
basis. The family doctor typically performs the physical and takes a
preoperative history a week or so prior. Tests, such as blood work and an
electrocardiogram, are done several days before the surgery. Pre- and
postoperative instruction are given on an outpatient basis. The patient
makes an appointment at the hospital, watches a video, and has an
opportunity to have questions answered, usually by a surgical nurse or
nurse educator. Any necessary preparation (e.g., not eating or drinking for
eight hours before the operation) is done at home by the patient (shave
preps are frequently omi ed). On the morning of the surgery, the
individual is admi ed, preoperative information not already obtained is
gathered, and the preoperative sedation, if any, is administered.
Considering the large number of surgeries that take place within each
province or territory each day, omi ing one night in hospital for every
patient results in a significant savings.
Day Surgery
Because of technological advances in many fields, particularly in
laparoscopic surgery, many surgeries are now done on an outpatient basis.
For example, the routine removal of the gallbladder (called a
cholecystectomy) once required a large abdominal incision, but now
requires only a small incision using a laparoscope. The patient, admi ed
as an outpatient, goes home the same day.
No ma er what the procedure, a patient seldom remains in hospital
longer than 2 or 3 days unless there are complications. Many other
procedures are also performed as day surgery including cataract surgery,
tubal ligations, hernia repairs, some gastrointestinal surgeries for cancer,
and increasingly, knee and hip replacement surgery. However, some
patients having designated day surgical procedure may encounter
difficulties, which prolong his or her hospital stay, each hospital day
adding to the cost.
Deliveries
For women having babies, the shorter the stay, the lower the cost for the
hospital. Most new mothers are discharged from hospital within 24 hours
(some within four hours) of an uncomplicated delivery and within two
days for a caesarian section. Deliveries of babies at home or in the hospital
with midwives are less expensive than a hospital delivery.
Bed Management
Efficient bed management is a priority for health care facilities across
Canada because of chronic bed shortages, costs associated with prolonged
hospital stays, and inappropriate assignment of beds to patients. Bed
management is sometimes called bed allocation management, patient
access and flow, electronic bed management, or patient navigation. All
terms refer to a system of policies and procedures used by hospitals to
coordinate efforts that will facilitate patient access to the right care in the
right place at the right time. These systems address the need for timely
admission and discharge from an acute care hospital to the appropriate
discharge destination. Bed management systems collaborate with home
and community care and long-term care facilities to optimize efficiency.
Timely Discharge
Even in the presence of effective bed management strategies, hospitals
endeavor to discharge inpatients by 10:00 or 11:00 a.m. Depending on the
policies of the jurisdiction, hospitals will be charged for an additional 24-
hour period if a patient is not discharged by a certain time, often noon. If a
discharged patient cannot arrange to leave before the discharge time, the
nurses will, if possible, have the patient vacate the bed and wait in a
lounge so that the room can be cleaned and readied for an admission.
Individuals undergoing day procedures are likewise kept until they are
deemed stable, and then discharged.
Palliative Care
Palliative care is provided to individuals with terminal illnesses. When
people become too ill to be cared for at home, they may be admi ed to
hospital for palliative care including pain control, which cannot be met at
home. However, many terminally ill people prefer to spend their
remaining time at home. A visiting nurse and other community support
services then provide the necessary care, supporting both the family and
the patient.
Palliative care facilities (hospices) are becoming more popular across the
country. The funding to build a hospice is often a joint effort involving the
municipal and provincial/territorial governments, and nonprofit
organizations (NPOs). Access to hospice care varies greatly across the
country. The 2016 Canadian Cancer Society publication (Right to Care:
Palliative Care for all Canadians) indicates that 13–59% of Canadians
suffering from cancer have access to palliative care and end-of-life services
(Canadian Cancer Society, 2016, p. 13). As our population continues to age,
the need for more hospice beds, specially trained health care providers,
and volunteers increases. The availability of palliative care services within
the community (at home or in a hospice) provides expert care to the
patient, supports the family members, and reduces both the number and
length of admissions to hospital.
Residential Care
Residential care refers to living accommodations that offer a variety of
support needs, usually for older adults. These accommodations include
lodges (public or private), assisted living or supportive services in the
community, and long-term care facilities.
Private Residences
Older Canadians, who can afford it and want to avoid long-term care
facilities, may choose to live in private residential facilities where they can
select the type of accommodation and level of care required.
Private residential accommodation can cost up to $200,000/year,
although this cost varies with location and the “luxury” components of the
facility. Choice of accommodation ranges from a single room to larger
more spacious suites. The more services required, the higher the cost.
Maximum care would be similar to that provided in a nursing home.
Federal, provincial, and territorial governments are not responsible for any
costs incurred and the resident pays the facility directly.
Drug Insurance
All provinces and territories provide some kind of drug insurance to
certain groups, such as older Canadians, people with disabilities, and
individuals who earn low incomes or are on social assistance. A co-
payment or deductible may apply (see Chapter 9), but some pharmacies
will waive deductibles and co-payments in certain circumstances.
Canada is one of only a few developed countries without a national
drug plan. However, most provinces and territories have some form of
catastrophic drug coverage, meaning they will assume the cost of very
expensive drugs for specific health conditions when the family is unable to
cover the expense. Quebec has had a provincial drug plan since 1997 for
those who do not have private drug insurance. However, as part of the
2018 budget the Federal Government announced the implementation of an
advisory council to study Pharmacare programs, which included look at
the international levels.
A drug’s accessibility and coverage through an insurance plan are
determined by its category; over-the-counter (OTC) medications can be
purchased without a prescription and are rarely covered by public or
private health plans; prescription medications can be purchased only with
a prescription from a health care provider (e.g., family doctor or specialist;
in some jurisdictions, nurse practitioner, or midwife) and may be covered
in part or in full by insurance.
Occasionally, a province or territory will remove a drug from the list of
drugs that may be obtained only with a prescription. Once removed,
however, insurance will no longer cover the drug.
Physicians
The gross (without any deductions) payments made to physicians for
clinical services in 2015–2016 was just under $28 billion. This was paid by
provinces and territories for insured medical services—the majority for
consultations and physician visits. A physician visit most often refers to an
assessment by a family physician or similar, and a consultation occurs
when one physician or other provider requests another physician to see a
patient to evaluate the patient’s condition. (CIHI, 2017c). See Case
Example 4.4.
Fee-for-Service
As mentioned above, FFS is the oldest and, for the moment, most widely
accepted method of physician payment in Canada. Using this method,
doctors charge the provincial or territorial plan for every service they
perform. Each province or territory has slightly different parameters for
FFS billing. Invariably though, the amount the doctor bills relates to the
complexity and length of the patient visit. Most jurisdictions have three or
four main categories for “visit fees” that a physician can charge for: a
minor assessment, an intermediate assessment, and a full assessment (e.g.,
a physical examination). In Ontario, a physician would bill about $33.70
for an intermediate visit and assessment, such as Pierre’s visit described in
Case Example 4.4.
Within the FFS model, doctors can also bill for things other than the
actual office visit. For example, doctors who make house calls can charge
more to ensure they are compensated for travel, for seeing a patient away
from the office, for the time of day or night the house call is made, and for
the patient visits cancelled if making a house call during office hours.
Doctors may also bill for procedures such as giving an injection, suturing a
wound, or for visiting a patient in hospital. Amounts billed also vary
depending on whether the doctor is the most responsible physician (MRP),
or is only providing a consultation. (In the hospital, the MRP is the
physician with the primary responsibility for caring for the patient; the
MRP may be the patient’s family doctor, but is usually a specialist.) Many
doctors prefer to retain FFS, at least in part. Some of the primary health
care reform models blend capitation-based funding (described below)
with FFS.
Because of advances in surgical techniques, many procedures (e.g.,
cataract surgery) can be done much faster than in the past. This enables
specialists to do many more procedures in a day; although they can bill the
same amount as they did when the procedure took a much longer time.
For that reason, many believe the guidelines determining the fees for
specific services need to be overhauled.
Capitation- or Population-Based Funding
Capitation-based funding (also called population-based funding) pays the
doctor for each rostered patient in his or her practice. This funding format
is often used by doctors in private practice who also operate under the
umbrella of an alternative health care delivery format, such as a primary
health care reform group. Rostered patients of a primary health care
network are asked to sign a form to say that they will seek medical
nonemergent care only from their family doctor or members of that
particular health care group. (For more details, see Chapter 5.) Physicians
must receive approval from their provincial or territorial government to
form such a group. Once physicians begin working in their selected
primary care model, they are usually paid monthly. With capitation-based
funding, doctors receive a set amount for each patient that is determined
by the patient’s age, health care needs, or both. Therefore a doctor would
be paid more per year for an 89-year-old patient with multiple health
problems than for a 22-year-old healthy patient. Whether the patient visits
the doctor once or 30 times in that year, the doctor receives the same
amount of money. Additionally, doctors are paid extra for achieving
certain milestones, such as immunizing a given portion of eligible patients
or doing routine Pap smears for women in high-risk groups. (Physicians
must track women in their practice and implement procedures to do Pap
smears in accordance with the criteria of the jurisdiction.) Se ing such
goals encourages doctors to be actively involved in disease prevention and
health promotion.
The fundamental components of capitation-based funding are
summarized as follows:
Indirect Capitation
Indirect capitation is a funding model through which an organization such
as a regional health authority receives a set amount of money to manage
health care—including staff, services, administrative costs, and capital
expenditures—for a population base. Employees within the organization
may be compensated in various ways.
Global Budget
Doctors practising in underserviced areas are paid a certain fee for
maintaining these practices. The global budget plan also usually includes
ample vacation time and educational leave.
Blended Funding
Most physicians in Canada who engage in a form of funding other than
FFS also partake in another method of payment. For example, a physician
in a primary health care network group can have a certain portion of his or
her practice nonrostered and on an FFS funding scheme, and another
portion calculated on capitation-based funding.
Specialists’ Compensation
At teaching hospitals, specialists may have teaching responsibilities and
receive a salary. Most specialists, even if on salary, maintain a private
practice as well. In their private practice, they see a patient upon referral
from a family doctor until the problem for which the patient was referred
is resolved.
Specialists not employed by a hospital or other organization rely on fee-
for-service and therefore bill the province or territory for services
rendered. Specialists belonging to a primary health care reform group may
receive other forms of compensation reflective of the payment formula for
that particular group.
In most jurisdictions, after a certain period of time (often one year), if a
patient’s health problem recurs, the patient may call the specialist’s office
directly and return for another evaluation (called a repeat consultation). If a
new problem occurs, or if the same problem returns after the designated
time period, the patient will need another referral (called a consultation
request) from his or her family doctor. In most jurisdictions, a person
cannot call a specialist’s office and simply make an appointment.
Channeling specialist visits through a primary care provider results in
specialists seeing only those patients who have legitimate problems and,
thereby, creates cost savings (CIHI, 2013).
Nurses
As discussed in Chapter 5 there are three categories of regulated nurses in
Canada—registered nurses, including nurse practitioners,
licensed/registered practical nurses, and registered psychiatric nurses
working in health care facilities, the community, and primary care
organizations.
The number of regulated nurses in Canada grew by nearly 16.4% over
the past decade with a total of 425,757 regulated nurses actively registered
to practise in Canada. Of these, 301,010 were registered nurses, including
5274 nurse practitioners, 118,810 licensed/registered practical nurses, and
5937 registered psychiatric nurses (CIHI, 2018a). Internationally,
graduated nurses make up just over 8% of the regulated nursing
workforce, and are primarily from the Philippines, India, and Great
Britain. Regardless of the statistical increase in regulated nurses in Canada,
shortages remain resulting from large numbers of nurses retiring, many
working outside the profession, and lack of funding for new hires (CIHI,
2017d).
Using the professional services of nurses in a cost-effective manner is
complicated. Each facility and workplace se ing requires a specific mix of
nursing professionals, particularly in a team se ing. As a rule, only
registered nurses work in hospital intensive care units and other highly
specialized se ings where patient care is both complex and acute. In other
patient care units, there may be a mix of registered nurses and licensed
practical nurses, the ratio depending on patient care needs. Long-term care
facilities are more likely to have fewer registered nurses, and a greater
number of licensed/registered practical nurses and personal support
workers. There is a chronic shortage of workers to meet the demands of
home and community care.
In most jurisdictions, hospitals are funded a certain amount of money
for a given time frame, either by a health authority or directly from the
Ministry. Some of that money is assigned to certain pockets for spending
(e.g., knee and hip surgery) and some for health human resources. The mix
of health professionals hired within the budget is determined by the
facility. Nurses working in hospitals, long-term care, and other public
facilities are usually paid by the hospital with funds received from the
government. Nurses in primary health clinics are paid through the clinic,
or by the physicians for whom they work. Nurse practitioners are paid by
the government or by physicians directly.
Midwives
In some provinces (e.g., British Columbia, Alberta, Ontario) midwives are
independent practitioners, paid a designated amount per course of care.
This amount can vary depending on the amount of time in practice and is
capped at between 40 and 60 births per year. A first-year midwife in
British Columbia earns $1400 per course of care, while an experienced
midwife gets $3120. The total number of births is capped at 60, though
most midwives’ average 40 to 60 births per year. In Alberta, midwives are
paid $4600 per course of care, but are capped at 40 births per year as the
primary caregiver. Therefore a base range for gross starting salaries paid
in this way would be $56,000 in British Columbia, $81,200 in Ontario, up to
as much as $184,000 in Alberta. Some Ontario midwives, notably those
working through the Indigenous Midwifery Program, are government
employees.
In the other provinces (e.g., Quebec and Saskatchewan), midwives are
paid government employees. The starting salary in Quebec is $54,000, plus
compensation for on-call time. Starting salaries in northern regions such as
Nunavut and NWT tend to be higher ($87,000 and $100,015, respectively,
plus northern living allowance), and in the case of NWT, overtime and on-
call pay. Therefore a starting base salary range for midwives paid as
employees (not including additional benefits) starts at $54,000 in Quebec
and goes up to $100,015 in NWT.
Other health care cost drivers
Technology
Technological change has had a significant impact on health care costs,
although it is difficult to assign a dollar value. Technology includes
information technology (electronic health records and electronic medical
records); medical devices, particularly those used for imaging; and tools
and procedures to carry out new surgical techniques, such as bariatric
(weight loss) surgery, which is expensive and in high demand.
Outsourcing
In many jurisdictions, health care services are contracted out to
independent facilities. In Ontario, for example, some independent health
care facilities have been licensed to perform MRI and CT scans for
medically necessary procedures. To prevent queue jumping, patients must
be referred to the facility for these procedures. The provincial government
claims that contracting out these services costs 36% less than operating the
same services within the hospital se ing (Government of Ontario, 2003).
These independent facilities may offer uninsured MRI and CT scans (e.g.,
to athletes or corporate executives whose firms cover such costs) only if
they have signed a contract with the government to offer a designated
number of insured scans per month. A company can only offer remaining
spaces to the private sector once the insured scans have been completed.
LEARNING OUTCOMES
KEY TERMS
Accredited program
Affiliating body
Allied health professional
Community-based care
Controlled act
Delegated act
Evidence-informed
Geriatrics
Health care provider
Hospice
Interprofessional collaboration
Intubate
Practice se ing
Primary care se ing
Refraction
Rostering
Scope of practice
Specialist
Telehealth
Title protection
Urodynamic
Conventional Medicine
Conventional medicine is frequently referred to as orthodox,
mainstream, traditional, or Western medicine. Conventional medicine
typically encompasses all those modalities not performed by
alternative practitioners. They diagnose health problems; treat
prediagnosed health problems; and render technical, therapeutic, or
supportive care with scientifically proven therapies, medication, and
surgery.
Thinking it Through
Janet was treated for breast cancer 2 years ago with an optimistic
prognosis. Last month, she went to her physician complaining of
shortness of breath. Magnetic resonance imaging (MRI) revealed
metastasis to both lungs (the spread of cancerous cells from their
original site). Janet’s oncologist recommended chemotherapy and
radiation. This time, her prognosis was guarded at best. Janet, based
on her former unpleasant experience with the side effects of these
treatments, decided to seek a homeopathic remedy. Considering
these alternatives, what would you do if you were this patient? If
you were a health provider and Janet approached you for advice
regarding her decision, how would you respond?
When a patient is using CAM, the best outcomes occur when the
patient, CAM practitioner(s), and medical practitioner work together
to ensure that no dangerous overlaps occur in care and treatments.
For example, herbal medicine can interfere with prescribed
medications. St. John’s wort, a common herbal supplement taken to
ward off depression, and prescription antidepressant drugs used
together can result in an overdose. Many people use herbal
medications (available over the counter at health stores and
pharmacies), but fail to inform their doctor. They may believe that
herbal medications are harmless, or they may be embarrassed or
fearful to admit to taking such medications, believing their physician
will disapprove. Health care that embraces both conventional and
complementary medicine can help to establish a trusting alliance
with patients, and provide medical and psychological benefits.
Title Protection
Regulated professionals—those who belong to a professional body—
are licensed to practise their profession and are legally entitled to use
a specific designation such as registered massage therapist (RMT).
These professions receive title protection, meaning only properly
trained persons registered and in good standing with their regulatory
body can legally use that title. For example, people who have cared
for loved ones at home but have no formal training cannot call
themselves licensed or registered practical nurses. Likewise, someone
who dropped out of college halfway through a respiratory therapy
program cannot call himself or herself a respiratory therapist. Nor
can health care aides call themselves nurses. Conversely, someone
trained on the job can call themselves a health care aid or equivalent
as there is no regulatory body legally preventing this title. Fully
trained nurses registered in other countries cannot call themselves
registered nurses here until they have met the standards set by the
college of nurses in the province or territory they want to practise in.
Along with title protection, regulated professions share other
collective elements (Box 5.1).
Box 5.1
Regulated Professions: Common Elements.
• Educational standards
• Provincial and territorial examinations
• Practitioner’s scope of practice, which outlines skills, acts, and
services the practitioner is able to perform competently and
safely
• Curbing of individual’s practice if standards are not met
• Formal complaints process for the public
• Complaints investigation and follow-up
• Title protection
• Competence and quality assurance
Any health care profession can apply to the government to become
regulated, but it must meet strict criteria. The minister of health and
some type of advisory body within the province or territory usually
oversee the lengthy and often arduous application process.
Just as the possession of a legitimate driver’s licence promises that
a person knows how to drive and has passed a driving test,
regulation proves a person has undergone training and gained a
predetermined degree of knowledge, skill, or ability. Possession of a
driver’s licence, however, does not guarantee driving excellence; even
in regulated professions, some health care providers offer
substandard services.
All regulated professionals must practise within a framework of
skills and services defined by their governing body. Nurses have
certain skills and acts they have been trained to do; physicians have a
range of skills and services they have been trained to offer; and
respiratory therapists, medical, and other health care practitioners,
likewise, have a defined scope of practice. Even within a single
profession, different levels of practice exist. For example, registered
nurses with special training (e.g., advanced practice) may perform
acts that those without this training cannot. Nurses usually have to
take specialized courses to acquire the skills to start an intravenous,
or managing wound care. Similarly, a medical doctor in family
practice is not qualified to remove a gallbladder or do a hip
replacement; a licensed practical nurse is not qualified to do a
complete physical, but a nurse practitioner is; and a massage
therapist is not qualified to deliver a baby, but a midwife, nurse
practitioner, or obstetrician is. In health care, many of these skilled
procedures, some specific to certain professions, are called controlled
acts.
Exceptions
Most provinces and territories allow controlled acts to be performed
in certain situations by competent yet nonregulated individuals,
including the following:
Exclusions also apply in the case of body piercing for the purpose
of jewellery, electrolysis, ta ooing, and ear piercing.
Thinking it Through
g g
Miranda, a personal support worker, is looking after an older
woman, Ibia. Ibia has not gone to the bathroom for several hours and
is very uncomfortable. Ibia’s visiting RN occasionally has to
catheterize her; however, the nurse is unavailable for a few hours.
Miranda, who is a fully qualified nurse from England, performed the
procedure, successfully draining off the urine, and making the
patient comfortable. Clearly, Miranda was performing a controlled
act that she was not qualified to do in Canada.
Delegated Acts
As our health care system continues to evolve, health care providers’
scopes of practice are also evolving. Reforms in the health care
system, in methods of delivery, and in health care providers’
responsibilities, have affected the traditional roles of health care
providers. The needs of patients also continue to change—more
complex care is required more frequently. For patient needs to be
met, occasionally the acts, procedures, and treatments rendered by
health care providers must go beyond standard boundaries.
A delegated act by definition is the means by which a regulated
health professional (authorized to perform the delegated act)
transfers legal authority or permits another person to carry out a
controlled act they are otherwise unauthorized to do (procedures that
are not controlled acts do not require delegation).
The delegated act may include a specific procedure, treatment, or
intervention that is not within the scope of practice of the person to
whom the act is delegated. For instance, a registered nurse working
in the community can delegate the act of giving an injection to a
nonregulated provider (personal support worker), or to a daughter
caring for her father at home. Physicians can delegate the act of
obtaining a pap smear to a nurse, or delegate the act of giving allergy
injections or immunizations to an administrative assistant. Not all
controlled acts can be delegated. Those that can be delegated are
defined by provincial and territorial regulations (under the
jurisdictions Regulated Health Professions). For example, a nurse
practitioner cannot delegate the act of prescribing a medication to a
registered nurse or an occupational therapist. A licensed practical
nurse cannot delegate the act of dispensing a medication to a
personal support worker, and a respiratory therapist cannot delegate
the act of intubating a patient to a physiotherapist, registered nurse,
or a nurse practitioner.
Acts in most jurisdictions cannot be subdelegated. This means that
a person accepting the responsibility of performing a delegated act
cannot assign someone else to carry out that act.
Guidelines and protocols for delegation of medical acts vary across
Canada. In some jurisdictions, controlled acts can be delegated only
to a person who is a member of a regulated profession, but in others,
certain acts may be delegated by a regulated health professional to a
nonregulated health care provider. Generally, the delegated act must
be clearly defined and supervised accordingly. Supervision can be
direct (i.e., the delegating health care provider is physically present),
or indirect (i.e., the delegating provider is available for consultation
by phone).
In most health care organizations, authorities such as a board of
directors or a medical advisory commi ee or their equivalents must
agree to the rules and procedures for delegated acts. This may be
agency specific, for example, identifying acts an RN may delegate to a
nonregulated care provider to perform. The health care provider with
expert knowledge has a commitment to his or her patient to ensure
that the person performing the act—called the delegate—is properly
trained and demonstrates competence in completing the act.
The delegating health care professional, the delegate, the facility, or
environment in which the act is performed share responsibility for
the act. The health care professional who teaches or assesses the
delegate’s initial performance of the delegated act (and determines
the delegate is competent) is accountable for ensuring the act is, in
fact, carried out competently. The person carrying out the act is liable
if he or she performs the act ineffectually.
Usually the patient or patient’s power of a orney for personal care
must give informed consent to allow someone other than the
regulated health care professional (for whom the act is within his or
her scope of practice) to perform a procedure. For acts typically
performed by physicians, delegation will occur only with the
patient’s consent and only after the physician has assessed the
patient, discussed the procedure, and answered any outstanding
questions. Details outlining regulations for delegated acts are
available on provincial or territorial websites for related nursing and
medical associations. It is worth noting that many colleges offer
courses to nonregulated individuals on carrying out certain
interventions (e.g., giving injections and administering medications)
(Case Example 5.1).
Complaint Process
Regulated professions have a system in place whereby the public can
launch complaints against a health care provider. A designated
commi ee investigates all complaints, protecting both the public,
who can rest assured that legitimate complaints will be looked into
and appropriate action taken, and health care providers, who will
have illegitimate or unfounded complaints against them dismissed.
Health care providers found to be at fault may face suspension, an
order for additional training, the loss of their licence to practise, or
even legal proceedings, such as a criminal investigation.
Educational Standards
A regulator of a profession has the authority to set educational
standards for the training of its professional members, including
theoretical and practical components of their education as well as
examinations for entry to practise. The educational process both
prepares professional members and also provides assurance to the
public that the health care provider is competent to practise.
Professional bodies often use competency-based assessment
programs to ensure the continued maintenance of practice standards,
protecting both the health care provider and the public. The
requirements may include the use of self-assessment tools,
participating in continuing education programs, keeping a record of
professional activities, or a combination of these. Often proof that
these standards have been met is a requirement for renewal of a
professional’s licence to practise.
Licence to Practise
In each province and territory regulators of professions, in
conjunction with educational facilities and in keeping with provincial
and territorial requirements, oversee the licensing of their members.
Regulated professions almost always require licence renewal
annually. Many now have other criteria that must be met, such as
peer reviews or other proof of ongoing education.
Moving from one province or territory to another can cause issues
for some professionals since not all regulated professions have
agreements and standards in place for members to practise in other
jurisdictions (Case Example 5.2).
Physicians
Entrance requirements for medical school vary across Canada, but
most universities require the applicant to complete 2 to 4 years of
undergraduate work, usually obtaining a bachelor’s degree, and then
write an entrance examination, called the Medical College Admission
Test (MCAT), before applying for placement in one of Canada’s
medical schools. Medical school consists of 3 to 4 years of study,
followed by a residency in the person’s area of specialty (e.g., family
medicine, internal medicine, general surgery).
A doctor with specialized training in one area, called a specialist,
usually sees patients only upon request from a family doctor or
another specialist. In fact, most provincial or territorial insurance
plans will not cover the cost of a patient visiting a specialist without
such a referral. A family doctor will refer a patient to a specialist (also
called a consultant) when the patient requires assessment and
treatment outside the family doctor’s scope of practice. Many
specialists work in solo practice; others work in private or public
organizations, or are employed by hospitals.
Family Physicians
Family doctors are also called general practitioners or primary care
physicians. With a wide knowledge base not limited to any specific
disease or system or to any particular sex or age group, the family
doctor provides ongoing care that includes the diagnosis and
treatment of conditions and diseases not requiring the care of a
specialist, counselling, health promotion and disease prevention, and
primary maternity and mental health care. Most family doctors work
in primary care team se ings (discussed later). A few remain in solo
practice, and some in various types of clinics or health centres,
especially in more remote regions of the country. Many family
doctors also oversee the medical care of patients in health care
facilities such as long-term care residences. Some still make house
calls, for which the patient must pay out of pocket, but that service is
not as prevalent as in the past. In addition, many family doctors now
choose to give up their hospital privileges, temporarily turning over
the care of their hospitalized patients to a hospitalist or other
specialist.
Emergentologists
Some physicians, called emergentologists, have chosen careers
practising full-time emergency medicine. This specialty has
developed because many emergency departments (EDs), also often
referred to as emergency rooms (ERs), are choosing to hire full-time
physicians, rather than staffing the ED with on-call physicians as in
the past.
Geriatricians
Geriatrics focuses on the care of older people, typically those over 65.
A geriatrician is usually an internist who has additional training in
caring for older adults.
Geriatrics does not a ract a large number of physicians. The
assessment and treatment of an individual with complex medical
conditions is time consuming. Additionally, geriatricians are typically
paid less than other specialists. Most work in private practice, team-
oriented practices, or health care facilities.
Cardiologists
Cardiologists specialize in conditions and diseases of the heart,
ranging from abnormal rhythms and heart a acks to related vascular
problems. The cardiologist treats patients from a medical perspective,
but does not do surgery. If surgery is required, the patient will be
referred to a cardiac surgeon. Aside from seeing patients in the office
se ing, cardiologists with special training may carry out diagnostic
procedures such as cardiac catheterizations in a hospital or private
diagnostic facility.
Neurologists
A neurologist treats conditions of the nervous system, including
chronic and potentially fatal conditions such as Parkinson disease
and multiple sclerosis, sleep disorders, headaches, peripheral
vascular disease, brain tumors, and spinal cord injuries. Neurologists
do not perform surgery. Patients requiring surgery would be referred
to a neurosurgeon.
Ophthalmologists
Ophthalmologists, medical doctors who specialize in diseases of the
eye, can carry out both medical and surgical procedures, such as
cataract removal and ocular emergencies (e.g., glaucoma, eye
trauma). Although ophthalmologists can perform refractions and
prescribe glasses, these functions have largely been taken over by
optometrists (who are not medical doctors). Cataract surgery is done
either in hospital or in free-standing medical facilities, such as Lasik
MD clinics or the Canadian Centre for Advanced Eye Therapeutics
Inc.
Oncologists
Oncology is the branch of medicine that deals with all forms and
stages of cancerous tumours—development, diagnosis, treatment,
and prevention. An oncologist specializes in the care and treatment of
people with cancer. Because cancer treatment has become so highly
specialized, oncologists may specialize in only certain areas, such as
radiation therapy, chemotherapy, gynecological oncology, or surgery.
Oncologists usually practise in large hospitals or medical centres
specializing in cancer treatment. They also provide ongoing
treatment for patients in hospices and related facilities.
Psychiatrists
Psychiatrists specialize in mental illness and emotional disorders,
including depression, bipolar disorder, schizophrenia, obsessive
compulsive disorder (OCD), borderline personality disorder, bulimia,
anorexia nervosa, and personal stress issues. As medical doctors,
psychiatrists can order laboratory and diagnostic tests and prescribe
medicine, unlike psychologists who are not medical doctors.
Psychiatrists do not perform surgical procedures. Geriatric psychiatry
is an emerging field.
Physiatrists
Physiatrists, medical doctors specializing in physical and
rehabilitative medicine, work closely with other health care
providers, such as physiotherapists, occupational therapists, and
geriatricians. Stroke and accident victims and postsurgical patients
are among the types of patients that a physiatrist would see.
Comprehensive care aims to restore the patient to his or her
maximum level of function. The family almost always plays a role in
the restorative and rehabilitative process, as treatment is usually long
and arduous. For this reason, social workers, psychologists, or
psychiatrists may also participate in the health care team.
Radiologists
A radiologist is a physician with additional training in the use and
interpretation of imaging techniques to diagnose and treat disease.
The radiologist is primarily a consultant to other physicians, but may
also be involved in the planning of patient care. Radiologists are
primarily found in large diagnostic centres, either hospital- or
community-based, private or publicly funded.
Respirologists
Respirologists, sometimes referred to as pulmonologists, are medical
doctors who further specialize in the diagnosis and treatment of lung
disease, such as asthma, emphysema, or pneumonia. Respirologists
perform tests to check how well a person is breathing and may use
procedures such as bronchoscopy to diagnose a breathing problem.
Surgeons
Surgeons complete their surgery residency in their field of choice,
usually over a period of 4 years or more, after completing medical
school. A general surgeon completes a number of rotations through
various specialties. General surgeons are qualified to perform a wide
range of procedures, mostly involving the gastrointestinal tract.
Many go on to further specialize in specific areas such as gynecology,
neurosurgery, or cardiovascular surgery. A surgeon’s scope of
practice varies with experience, specialty training, and level of
comfort with the type of surgery they are asked to perform (Case
Example 5.4).
Case Example 5.4
Roberta presents in the ED complaining of chest pain. Investigation
reveals she has a blockage in a major artery serious enough to
require surgery. Dr. Xiong, a general surgeon, is on call. Dr. Xiong is
qualified to assess Roberta’s condition but has no special training in
cardiovascular surgery. Roberta is referred to Dr. Silanka, a
cardiovascular surgeon who completes all required examinations
and tests and performs the surgery.
Nurses
Many agree that the nurse, with skills across several disciplines,
remains the backbone of the health care system in hospitals, primary
care se ings, and in the community. Multiskilled and flexible, with a
broad knowledge base, nurses frequently assume responsibilities
typically assumed by other members of the health care team. For
example, when a respiratory therapist is not available, the nurse may
do the inhalation treatments or set up oxygen for a patient; when a
physiotherapist is unavailable, the nurse ambulates a patient and
supervises his or her related exercises; when the chaplain is not
available, the nurse counsels and comforts the patient and loved
ones. When the clinical secretary is ill, the nurse may also assume
administrative responsibilities for the patient care unit.
Registered Nurses
All Canadian jurisdictions except Quebec require bachelor degrees in
nursing (BN or BScN) to enter the profession. Degrees in nursing can
be completed in 2, 3, or 4 years. Accelerated (2-year) programs are
available across Canada. The related regulatory body in each
province or territory must ensure that the individuals seeking to
practise as nurses meet designated levels of competence. To that end,
program graduates in all jurisdictions except Quebec must write a
national examination.
Introduced in 2015, the National Council Licensure Examination
(NCLEX-RN) replaces the Canadian Registered Nurse Examination
(CRNE) as Canada’s national examination. Applicants for registration
as a registered nurse (RN) are required to successfully complete the
NCLEX-RN exam, administered by the National Council of State
Boards of Nursing (NCSBN). Some jurisdictions require additional
examinations. In Quebec, in addition to a provincial examination,
applicants must pass a Language Proficiency Licensure Examination
administered by the Office Québécois de la Langue Française—in
accordance with Article 35 of the Charter of the French Language.
Those applying to practise in Ontario must also write a jurisprudence
examination, which tests knowledge about provincial nursing and
health care legislation.
Postgraduate and ongoing educational opportunities for RNs vary
among provinces and territories. Some specialties include critical
care, emergency nursing, community health nursing, hospice and
palliative care, and perinatal and woman’s health.
The RN usually assumes the most complex components of nursing
care and also a variety of leadership roles both clinical and
administrative. Many hospitals and other facilities employ RNs only
in specific areas, such as intensive care units where their specific skill
sets, particularly in assessment and decision making, are critical.
The number of RNs practising in Canada dropped by 0.3%
between 2014 and 2015, but increased by 2.2% between 2014 and
2016, with 95.6% of RNs/NPs working within the profession. In 2015,
just over 60% of RNs were employed full-time (Canadian Institute for
Health Information, 2016).
Nurse Practitioners
Nurse practitioners (NPs) are registered nurses with advanced
training and skills (RN Extended Class), authorizing them to practise
in an expanded role with many of the skills and responsibilities
formerly relegated to primary care physicians. NPs can
autonomously diagnose and treat health conditions, order and
interpret some laboratory and diagnostic tests, and prescribe a wide
range of medications, including controlled substances (e.g., recently
in British Columbia, methadone, an opioid agonist). As with other
providers, NPs incorporate health education, disease prevention, and
health promotion in their treatment plans. In addition, NPs can carry
out specified controlled acts and activities that other nurses, by law,
cannot.
There are approximately 28 postgraduate facilities offering NP
programs in Canada, the majority at the masters and postmasters
levels. Many of these programs are funded by their respective
provincial/territorial governments.
To obtain a licence to practise as an NP, individuals must be
registered and in good standing with their regulatory body in the
jurisdiction where they completed their NP education program.
Registration exam requirements for NPs vary among the provinces
and territories. In Canada, there are three broad streams (or
specialties) in which the NP can practise: adult, family (also referred
to as primary health care), and pediatrics. In some jurisdictions,
neonatology is another area.
Candidates must write an examination specific to their chosen
specialty. Quebec has different specialties than other jurisdictions,
including cardiology and nephrology. British Columbia and Quebec
have a clinical examination, called the objective structure clinical
exams (although they differ in each province). All other jurisdictions
have only wri en exam requirements. As with protocols governing
licensing criteria, NP competencies vary among provinces and
territories reflective to the related legislation in each region
(Canadian Association of Schools of Nursing, 2014; Case Example
5.5).
NPs, like other regulated nurses, must renew their licence yearly.
This usually involves practising a minimum number of practice hours
and participation in designated quality-assurance programs, ongoing
education, or both.
Practice se ings include primary care and community se ings,
hospitals under specialty designations (e.g., pediatrics, cardiology),
and in emergency departments. In 2016, NPs had the highest full-
time employment rate among regulated nurses in Canada (Canadian
Institute for Health Information, 2017).
Physician Assistants
Physician assistants (PAs) are academically prepared health care
providers who work directly with or under the direction of a
physician. Their responsibilities are usually outlined in a formal
contract between the PA and the physician(s) and may sometimes
include the facility in which they work. The PA’s scope of practice
ranges from interviewing patients and health teaching to performing
physical examinations and selected diagnostic tests.
To become a PA, the person must first have a Bachelor of Science
degree. Certification is awarded upon successful completion of an
entry-to-practice examination, after completion of a 2-year Canadian
Medical Association–accredited program. A PA program offered by
the Canadian Armed Forces Medical Services School in Borden,
Ontario, provides training for the military; civilian programs are
limited and offered only in selected jurisdictions. The Provincial
College of Physicians and Surgeons regulates PAs in Alberta,
Manitoba, and New Brunswick. The terms under which they practise
in other jurisdictions vary. In Ontario, where the profession is
currently unregulated, a PA may work under the Designated Medical
Act and only under the direction of a physician. Physician assistants
cannot practise independently.
Pharmacists
A licensed pharmacist, among other things, dispenses medications in
response to prescriptions. Experts in their field, pharmacists provide
other members of the health care team with valuable information
about medications. The physician looks to the pharmacist for advice
about current prescription drugs and their interactions. The patient
looks to the pharmacist for direction and advice about taking
medications, their risks, and adverse effects. In most jurisdictions, the
provincial or territorial plan will pay pharmacists to periodically
review a person’s medication profile, offer advice and counselling or
refer the person to his or her physician if need be.
To practise pharmacy, a person must earn a bachelor’s degree in
pharmacy, complete an internship, and successfully pass a national
board examination through the Pharmacy Examining Board of
Canada. Increasingly, pharmacists are assuming expanded roles from
giving flu shots to providing funded information sessions and
medication reviews with patients. They are recognized as experts in
medication management. Prescribing responsibilities vary across
jurisdictions. Most pharmacists can renew or prescribe a limited
number of medications (e.g., in the Northwest Territories [NWT],
Yukon, and Nunavut, with some exceptions). Only Alberta allows
pharmacists to independently prescribe a schedule 1 drug (those with
a high potential for addiction) if the pharmacist has met certain
requirements. Saskatchewan, New Brunswick, Manitoba, Nova
Scotia, Quebec, and the territories are not allowed to make
therapeutic substitutions for prescribed medications; all jurisdictions
with the exception of Quebec and the territories allow pharmacists to
give designated vaccines (e.g., travel and flu). Many jurisdictions,
including British Columbia, Alberta, Saskatchewan, Manitoba, New
Brunswick, Nova Scotia, and Prince Edward Island, allow
pharmacists to write prescriptions under designated guidelines.
Ontario pharmacists can prescribe smoking-cessation drugs and give
flu shots. Since September 2013, Quebec pharmacists have been
authorized to write prescriptions, give extensions on existing
prescriptions, adjust medication doses, and order and interpret
laboratory tests. Pharmacists in some jurisdictions may also order
certain lab tests. Those in Manitoba, Alberta, and Quebec can order
designated lab tests, with approval in Saskatchewan, New
Brunswick, Nova Scotia, and PEI pending. Pharmacists can also
change drug dosage or formulation everywhere except in the
territories. The goal of adding new responsibilities to the scope of
practice for the pharmacist is to reduce the volume of work for
doctors, clinics, and emergency departments, and to provide
Canadians with easier access to front-line services (Canadian
Pharmacists Association, 2016).
Midwives
Depending on the jurisdiction, women experiencing normal
pregnancies may choose to see a midwife. Midwives provide prenatal
care (before the baby’s birth), deliver the baby (either at the patient’s
home, in a birthing centre, or in the hospital), and provide
postpartum (after the delivery) and newborn care for up to 6 weeks
after the birth. Midwives, in accordance with jurisdictional guidelines
will refer a mother to a physician, usually an obstetrician, if her
pregnancy becomes high-risk or shows signs of other problems
during any phase of the pregnancy, labour, or delivery. A placenta
previa (low-lying placenta), or a multiple pregnancy, for example,
would be considered high risk. In some jurisdictions a midwife can
still provide prenatal care and work collaboratively with a physician
until the time of, and after delivery.
Midwifery is licensed in most jurisdictions in Canada. New
Brunswick licensed the province’s first midwife in early 2017. To
register as a midwife in New Brunswick, the (qualified) midwife
initially must meet provincial standards and be hired by the New
Brunswick Regional Health Authority. Once a midwife is registered,
he or she can work anywhere in the province. Provincial regulations
are determined by the Midwifery Council of New Brunswick.
Licensing midwives in Prince Edward Island is pending. Midwifery
remains an unrecognized profession in the Yukon Territory, although
the Community Midwifery Association of Yukon (CMAY) was
founded in January 2015 to advance the introduction of the
profession to the territory. Midwifery regulations in Newfoundland
were passed in April 2016 and came into effect on September 30 of
the same year.
Osteopathic Physicians
Osteopathy incorporates a holistic, manual approach to the diagnosis
and treatment of disease. It considers, in particular, the
musculoskeletal system and its relationship with the rest of the body
in terms of self-healing, self-regulating capabilities. Osteopathy is
practised in many countries but remains a nonregulated profession in
Canada. International standards for basic training, skills, and
responsibilities are set out by the World Health Organization (WHO).
The WHO describes two types of training. Individuals with no
health background must complete a 4-year university program with a
mandatory clinical component; those with health care backgrounds
complete a modified training program. Osteopathic physicians are
those individuals who have trained in the United States and who
hold a medical degree from a university approved by the American
Osteopathic Association. Their qualifications are the same as those for
a medical doctor, and if they have completed the provincial/territorial
requirements, may practise in Canada.
There are numerous schools of osteopathy across Canada
graduating students who can practise as osteopathic manual
practitioners or therapists. Although they may belong to related
associations, as a nonregulated profession there is no governing
legislative body that provides oversight, sets standards of education
and practice, or provides protection to those seeking their services
(e.g., preventing practice by unqualified practitioners). By law,
osteopathic manual practitioners or therapists cannot call themselves
osteopaths or osteopathic doctors—titles which have protection in the
United States. Some insurance companies will pay for their services if
the practitioner has graduated from a recognized facility.
Podiatrists (Chiropodists)
The term podiatrist is used internationally as the name for a foot
specialist. In Canada, only Ontario uses the term chiropodist.
Podiatrists specialize in the diagnosis, assessment, and treatment of
foot disorders. They treat sports injuries, foot deformities (related to
the aging process, as well as misalignments), infections, and general
foot conditions, including calluses, corns, ingrown toenails, and
warts. Included in their scope of practice is performing specified foot-
related surgical procedures, administering injections to the feet, and
prescribing medications (e.g., nonsteroidal antiinflammatory drugs
and antibiotics, depending on the jurisdiction). Podiatrists refer
patients to surgeons or other doctors when necessary.
In Canada, the chiropody/podiatry program is offered only at the
Michener Institute in Toronto. Although Quebec offers a podiatry
program for residents of the province, students are required to do 1
year of training in New York. Individuals can also be trained in the
United States, the United Kingdom, and Australia. Practice
requirements and scope of practice vary from one jurisdiction to
another. In jurisdictions with no regulatory body, there are no
standards of practice; essentially anyone can call him- or herself a
podiatrist and treat patients.
Practice se ings include health care facilities, clinics, the
community, primary care reform groups, and private practice. Some
podiatrists specialize in such areas as biomechanics, diabetic foot
care, or foot care in long-term care facilities.
Thinking it Through
Currently PSWs are not regulated in Canada, yet they make up a
growing sector of the health care landscape. Across the country,
there have been suggestions to provide oversight to this group of
caregivers, ranging from a registry to the creation of self-regulated
organizations. A registry can keep track of such things as a PSWs
employment history and credentials. However, a registry has no
authority to manage (or investigate) complaints. The complainant is
advised to contact the employer. A regulated body, on the other
hand, would provide the same safeguards for patients and PSWs as
other regulated professions. Do you see a need for some type of
oversight for PSWs? Why or why not? Would you choose a registry
or a self-regulated body?
Psychologists
Psychologists graduate from university programs at the bachelor’s,
master’s, or doctoral level. To practise psychology in Canada,
psychologists must be licensed by the regulatory body in the
province or territory where they work.
Psychologists work primarily as clinicians in hospitals, academic
facilities, clinics, primary care facilities, correctional facilities, and
private practice. Psychologists work with individuals and families to
treat emotional and mental disorders, mainly through counselling.
They administer noninvasive wri en and practical tests such as
personality tests, intelligence tests, assessment tests for a ention
deficit disorder (ADD), and diagnostic tests for the early stages of
Alzheimer disease or dementia. Since psychologists are not medical
doctors, they do not have the authority to prescribe medications,
perform medical procedures, or order lab or diagnostic tests. Often, a
psychiatrist and a psychologist will work as a team for more effective
and ongoing patient treatment. Private insurance usually covers a
specified number of visits to a psychologist; for the most part,
provincial and territorial plans do not.
Respiratory Therapists
To become a respiratory therapist (RT), one must successfully
complete a RT program from a college or university that has been
accredited by the Council on Accreditation of Respiratory Therapy
Education. College programs are 3 years in length; university
programs are 4 years long. The Canadian Society for Respiratory
Therapists (CSRT) is the national professional association for
respiratory therapists and the certifying body for RTs who practise in
nonregulated jurisdictions. In regulated provinces, provincial
regulatory bodies provide the certification for RTs. To obtain the RT
designation and be licensed to practice in Canada, graduates of
accredited programs in respiratory therapy must write the national
certification examination and meet designated registration criteria
from CSRT and their respective regulatory bodies.
Respiratory therapists have expertise caring for individuals with
acute and chronic cardiorespiratory disorders and perform health-
related functions—both in and out of hospital se ings. In the hospital
se ing, they are available to evaluate, treat, and support inpatients
and outpatients throughout the facility; however, they are especially
vital within critical care areas such as the ED, and intensive care
units, where they manage advanced life support for patients with
cardiopulmonary problems (e.g., persons on respirators). With their
advanced skills, RTs respond to emergencies (such as cardiac and
respiratory arrests) and are able to intubate patients (a complex
procedure inserting a tube into the airway to facilitate the use of a
ventilator) and initiate the use of ventilators. RTs are often required
in the transfer of critically ill patients from one facility to another or
from an accident scene to a hospital. They are also required in the
delivery room when doctors suspect the baby has or may develop
respiratory problems. RTs perform diagnostic testing, including
arterial blood gases, and pulmonary function tests. In the hospital
se ing, the RT is often responsible for se ing up oxygen therapy or
inhalation treatments. RTs also work in medical centres, clinics,
complex continuing care and rehab facilities, and in the community.
Physiotherapists
Physiotherapists (PTs) are regulated health care professionals who
graduate from university at the master’s level and must pass a
national exam to enter professional practice. An essential part of the
primary care team, PTs work with individual patients to limit and
improve upon physical impairments and disabilities, and to prevent
and manage pain related to acute and chronic diseases and injury.
They work in a variety of se ings such as health care facilities and
clinics, as part of a primary care team, in the community (home care),
and in private practice, often in groups. Some PTs specialize in such
areas as geriatrics, sports medicine, or pediatrics. Most jurisdictions
cover physiotherapy services under specific conditions and for
limited time frames. Many private insurance plans also offer some
coverage.
Occupational Therapists
Occupational therapists (OTs) are members of a regulated profession
who provide support, direction, and therapies to individuals in need
regarding almost every aspect of everyday life, from recreation and
work to the activities of daily living. For example, they help people
learn or relearn to manage important everyday activities, including
caring for themselves or others, maintaining their home, participating
in paid and unpaid work, and engaging in leisure activities. OTs
work with patients who have difficulties as the result of an accident,
disability, disease, emotional or developmental problems, or aging. In
most jurisdictions, individuals can visit OTs without a referral,
although the decision to see an OT is usually made jointly with a
primary care provider. OTs work in hospitals, private homes (usually
through provincial or territorial home care programs), schools, long-
term care facilities, mental health facilities, rehabilitation clinics,
community agencies, public or private health care offices, and
employment evaluation and training centres.
To practise as an OT in Canada, the minimal educational
requirement is a baccalaureate degree in occupational therapy. All
OTs must be registered with their provincial or territorial college.
Upon passing the national certification exam, OTs can practise
anywhere in Canada.
Administrative Roles
Health Information Management
Health Information Management (HIM) professionals hold the
designation of CHIM—Certified in Health Information Management.
They provide leadership and expertise in the management of clinical,
administrative, and financial health information in all formats and in
a variety of se ings (e.g., hospitals, community care, long-term care
and nursing homes, physician offices, clinics, research facilities,
insurance companies, and pharmaceutical companies).
The Canadian College of Health Information Management
(CCHIM) administers the National Certification Examination (NCE)
on behalf of the Canadian Health Information Management
Association (CHIMA), the national body representing approximately
5000 HIM professionals. To become a CHIM, one must graduate from
a CHIMA accredited diploma or degree program, offered at colleges
and universities across the country, and successfully pass the
National Certification Examination, which is offered at one level
countrywide. This examination assesses the entry-level competencies
of qualified applicants.
Successful candidates receive a certificate of registration in the
Canadian College of Health Information Management and are
eligible to use the CHIM credential and the title Certified HIM
Professional.
Certified members of CHIMA are required to participate in earning
continuing professional education (CPE) credits to maintain their
certification. Conestoga College in Ontario offers a Bachelor of Health
Information Sciences (BAHIS) degree and will also consider
graduates of CHIMA accredited HIM diploma programs for
advanced standing opportunities. Detailed contact information on
current CHIMA accredited programs, including those offered
through distance education, can be found on the CHIMA web site.
The HIM profession has four domains of practice: data quality (the
collection and analysis of health information, the coding of clinical
information, and quality assurance); e-HIM—electronic health
information management (the physical to digital conversion of health
records, digital cloud storage and distribution of health information,
and the management of complex communications systems); privacy
(keeping health information confidential and secure, and enforcing
privacy legislation as it pertains to the information for which they are
responsible); and HIM standards (records management standards,
documentation standards, terminology standards, etc.).
Health information managers are involved with almost every
aspect of health information throughout its lifecycle, from data and
information collection, analysis, and retrieval, to the destruction of
information once it is no longer needed. For example, when working
with health records, HIMs facilitate the collection of health
information and oversee proper access to and use of the information.
They ensure that data are stored properly and safely, and when no
longer needed, are disseminated and destroyed according to facility
and legal guidelines. HIMs also conduct quantitative analysis of
health records, ensuring they are accurate and complete, and
statistical analysis used for identifying trends, such as births, deaths,
diseases, and health care costs.
In Canada, HIM professionals are trained in six core competency
areas that include biomedical sciences; health care systems in
Canada; health information, including the HIM lifecycle; information
systems and technology; management aspects; and ethics and
professional practice. The HIM professional is playing a pivotal role
as Canada continues to work toward the implementation of
integrated electronic health information systems at local, provincial
and territorial, and national levels. They will be instrumental in
directing and reshaping how health care is delivered.
Alternative Practitioners
Alternative practitioners are valuable contributors to the health and
wellness of Canadians. Some disciplines have provincial or national
organizations with varying levels of oversight by their associated
bodies. Most are unregulated, meaning that there is not a legislative
body governing standards of education and practice, and providing
protection for both the patient and practitioner. Educational
requirements vary greatly within the discipline, and across provinces
and territories. Practitioners who practise acupuncture, for example,
often come from regulated professions such as chiropractic and
physiotherapy, who meet required criteria to practise acupuncture.
Chiropractors must complete over 200 hours of clinical training in
addition to taking the required courses and pass examinations
offered by Acupuncture Canada.
Volunteer Caregivers
Friends, family, and volunteer caregivers (who work in partnership
with professional caregivers) provide tremendous support to those
who are ill. With current shortages in all categories of health care
providers, many patients depend on this group of people to fill in the
gaps in their care that cannot otherwise be filled. The hours of care
provided by these individuals are uncountable, the output
unequalled, and the stress phenomenal. Many ill people could not
manage without this supportive network.
Practice settings
The practice (or workplace) se ings described here provide a cross
section of where health care is delivered. Included in some detail are
practice se ings that interdisciplinary teams work in. Several types of
clinic se ings are also described.
Thinking it Through
An older family member falls ill and requires constant supervision at
home for a period of time. Home care options are limited. Assume
that you work full-time and have a family of your own.
Clinics
Urgent Care and Walk-In Clinics
Canadian residents who do not have a family doctor, are away from
home, or cannot get an appointment with their primary care
physician can seek medical care from an urgent care or walk-in clinic.
These clinics reduce the burden on emergency departments by
providing nonemergency care to patients who would otherwise clog
the ED. Typically clinic visits are less costly to the health care system
than visits to the ED. Some urgent care clinics offer more immediate
access to diagnostic testing, such as ultrasound, and to minor
procedures, such as suturing, whereas walk-in clinics often refer the
patient elsewhere for these procedures.
Outpatient Clinics
Outpatient clinics offer services that vary from hospital to hospital
and community to community in an effort to meet the unique needs
of a particular area. An outpatient clinic can operate under the
umbrella of an ambulatory care clinic—a clinic within a clinic.
Services may include family doctor care, minor surgery, screening
procedures (e.g., vascular screening), laboratory and diagnostic
procedures, and foot care. Outpatient clinics in large hospitals offer
an even wider range of services. Some hospitals divide clinics into
areas of specialty and related services; others offer many disciplines
within one clinic. For example, in Moncton, New Brunswick, the
hospital has divided its ambulatory care clinics into five specialized
areas: healthy living (including services to assess and treat ongoing
conditions such as asthma, diabetes, and chronic obstructive
pulmonary disease); specialty procedures clinics (including
urodynamic and eye clinics); treatments and orthopedics; diagnostic
clinics (including pulmonary assessment and electrocardiograms);
and endoscopy and minor surgery.
Methadone Clinics
In a methadone clinic, the drug (a synthetically produced opioid) is
used to treat individuals addicted to other opioid drugs including
heroin, oxycodone, and fentanyl. This treatment is sometimes also
called opioid replacement therapy.
Physicians prescribe low doses of methadone that are carefully
titrated to the individual’s needs. Those undergoing treatment come
from all walks of life, many holding down full-time jobs in a variety
of professions, but are addicted to opioids and looking for a way to
overcome it.
Methadone treatment in itself is not a cure for drug addiction. It
aims to prevent acute opioid withdrawal. Individuals undergoing
methadone treatment must adhere to a strict regime including daily
visits to the clinic for regular blood and urine testing. Most clinics
provide patients with support, including counselling to help them
understand opioid addiction, and how opioid replacement therapy
works.
Physicians must have special permission to prescribe methadone
under section 56 of the Federal Controlled Drugs and Substances Act
and (in most jurisdictions) be sanctioned to do so by their licensing
body (Government of Canada, 2017). British Columbia,
Saskatchewan, Ontario, and Quebec have their own provincial
protocols for prescribing methadone, with the remaining jurisdictions
following Health Canada policies.
Forming a Group
A number of family physicians can unite to create a primary health
care group. They first need to choose what particular model or
framework they want to use (it must be an acceptable model within
their province or territory). In most jurisdictions, the physicians must
apply to the provincial or territorial government or the appropriate
body for permission to form the group. Once approved, they enter
into a formal contract with their provincial or territorial government,
which details the organizational structure, funding mechanisms, and
their professional obligations to the group and patients (e.g., hours of
availability, clinic hours, telephone availability). The obligations and
funding for other members of the group (depending on the mix of
health care professionals) is also determined by the type and nature
of the model. Organizations can also be modified to reflect the
contextual, cultural, and geographic needs of the communities they
serve.
Thinking it Through
You move to a new town and set out to find a family doctor. You find
one physician in solo practice who agrees to take you as a patient
because he cares for friends of yours. However, you also find a
newly formed primary health care group with two physicians taking
new patients.
Consider the benefits the primary health care group offers versus
the close relationship you would be likely to develop with the
physician in solo practice. Which would you choose?
Telephone Helplines
All jurisdictions offer confidential telephone help assistance free of
charge to those who need it. Helpline names vary, for example
Telehealth in Ontario, Healthline in Newfoundland and Labrador,
and Health Link in Alberta. Helplines offer callers advice from health
care providers (usually RNs) 24 hours a day, 7 days a week. Nurses
will not provide callers with a diagnosis, but will answer questions,
and if needed, direct the caller to the appropriate resource or level of
care, ranging from the person’s primary care provider to a clinic or
emergency department. Alternatively, the nurse may provide advice
to callers on how to handle a situation themselves. In addition to
provincial/territorial help lines, some primary care groups have their
own helplines. See Case Example 5.10.
Case Example 5.10
Helena lives in British Columbia and has a 3-year-old daughter,
Gillian. Gillian wakes up at 2:00 a.m. She is warm, crying, and has
diarrhea. Helena is not sure what to do. Should she take Gillian to
the emergency department, or is it something that can wait until
morning? Helena calls HealthLink BC, which offers British
Columbians health information and advice from a registered nurse
around the clock. The nurse gives Helena some advice on how to
care for the li le girl, feeling it is nothing serious enough to warrant
a visit to the ED. She tells Helena to call her family doctor in the
morning if she is still concerned about her daughter, which Helena
does. In the meantime, HealthLink BC transmits an electronic report
of the occurrence to the family doctor’s office.
LEARNING OUTCOMES
Key terms
Disease prevention
Health indicators
Health promotion
Inequities in health
Population health
Primary care
Primary health care
Public health
Qualitative research
Quantitative research
Upstream investments
How healthy are Canadians? What is most affecting their health? What do
we need to do to prevent illness in ourselves and in our children? Are we
proactive enough in looking at health determinants in our own
communities? How can we best implement population health and health
promotion initiatives within our communities or within our provinces or
territories? Do we know enough about the profound effects of the
socioeconomic determinants of health and how they affect individuals and
entire communities? Are we able to identify and address inequities in
health care, especially for marginalized Canadians? Do the socioeconomic
determinants affect those living in geographically isolated communities
differently than those in our urban centres? What barriers do refugees and
new Canadians face with respect to the determinants of health, and access
to equitable health care?
The answers are found in a population health approach to health care.
These approaches involve all levels of government, communities,
individuals, and other stakeholders.
Population health
Population health refers to the identification of the health outcomes of a
population group and the equitable sharing of those outcomes with that
group. A population or a population group can be defined by: ethnicity,
geography, a nation, a province or territory, a community, or a se ing
(e.g., within schools, or the workplace).
A population health approach looks at health in broad terms. It
considers health to be a resource influenced by numerous factors
identified in the determinants of health. A population health approach
aims to improve the health status of a targeted population, rather than that
of the individual. It is a framework for gathering and analyzing data around
related factors that affect a population’s health. This analysis includes
identifying the reasons why some groups are healthier than others.
Subsequent action looks for ways to improve health and to address
inequities in health status through reductions in material and social
imbalances.
The benefits of a population health approach extend beyond improving
the health of a population group to building a sustainable and integrated
health care system that meets the needs of a population, is flexible,
effective, and equitable.
Population health embraces broader definitions of health and wellness
incorporating holistic concepts. Population health integrates public health
initiatives such as health promotion and disease prevention. Public health
transforms the recommendations from population health research into
action (e.g., proposing that all children receive the recommended
vaccinations, implementing health education initiatives). Public health
strategies are funded and implemented by provincial/territorial and
municipal governments, which involve collaboration with health care
providers, industry, and community agencies. Social media also plays a
significant role in the public health arena by providing a platform for
public health campaigns; it is a distribution channel for health information
(e.g., educational, preventive, and cautionary), and helps to improve
health outcomes (see Chapter 10).
The terms population health and public health are often used
interchangeably but are different entities with a common denominator—
health information. See Box 6.1 for an explanation of the differences
between population health and public health.
Box 6.1
Population Health Versus Public Health.
Box 6.2
Alma-Ata Definition of Primary Health Care.
Primary health care is essential health care based on practical,
scientifically sound, and socially acceptable methods and technology
made universally accessible to individuals and families in the community
through their full participation, and at a cost that the community and
country can afford to maintain at every stage of their development in the
spirit of self-reliance and self-determination.
Thinking it Through
The Declaration of Alma-Ata identified primary health care as the key
strategy for a aining universal health by the year 2000. “Health for All”
was universally accepted as the main social goal (i.e., not merely a health
goal) by the world health community. Today efforts to improve the
delivery of primary health care are underway in all regions across
Canada, yet thousands of individuals remain without family doctors.
Thinking it Through
Some people believe Canada should have universal day care wherein it is
available to every child. Some think that day care should be available to
families based on their ability to pay (i.e., free for some, subsidized for
others). There are also individuals who feel that child care should be the
responsibility of the family and that government involvement only adds
to the taxpayer’s burden.
Box 6.4
Strategies for Improving the Health of Canadians.
Thinking it Through
Today a higher education does not guarantee a good job and income
security. Large numbers of university graduates cannot find jobs in their
fields and take lower paying jobs that are unrelated to their skill set. In
2017, the unemployment rate for individuals between the ages of 15 and
24 was almost 13%, significantly higher than the rest of the general
population at 5.7% (Statistics Canada, 2017b; Trading Economics, 2018). In
addition, tuition fees in Canada have doubled since the late 1990s.
Statistics Canada estimated the average cost of an undergraduate degree
to be $23,000 and that does not include supplies or cost of living
(Workopolis, 2016). There are twice as many university graduates
competing for available jobs.
1. If these trends continue, what effect do you think they will have on
the economy?
2. How does this information contradict the indicators related to
income, social status, and the SES?
3. How might these trends affect individuals with respect to their
health status? Why?
Sources: Statistics Canada. (2017). Labour Force Survey, December 2017. Retrieved from
h ps://www150.statcan.gc.ca/n1/daily-quotidien/180105/dq180105a-eng.htm; Trading
Economics. (2018). Canada—unemployment, youth total (% of total labor force ages
15–24). Trading Economics. Retrieved from
h ps://tradingeconomics.com/canada/unemployment-youth-total-percent-of-total-
labor-force-ages-15-24-wb-data.html; Workopolis. (2016). The university degrees with
the greatest payoff on the Canadian job market. Retrieved from
h ps://careers.workopolis.com/advice/the-university-degrees-with-the-greatest-
payoff-on-the-canadian-job-market/.
Sources: Brennan, R. J. (2015). Ontario set to replace welfare cheques with debit cards.
The Star. Retrieved from
h ps://www.thestar.com/news/queenspark/2015/03/19/ontario-set-to-replace-
welfare-cheques-with-debit-cards.html; Citizens for Public Justice. (2017). Poverty
trends 2017. O awa. Retrieved from h ps://www.cpj.ca/poverty-trends-2017;
Cryderman, K. (2012). Low-income Albertans and disability workers get boost in
2012 budget. Inclusion Alberta. Retrieved from:
h p://inclusionalberta.org/news/2012/02/09/news-item/low-income-albertans-and-
disability-workers-get-boost-in-2012-budget/; Statistics Canada. (2016). 2016 census of
Population. Aboriginal identity, individual low-income status. Catalogue no. 98-400-
X2016173; Statistics Canada. (2017). Household income in Canada: Key results from the
2016 census. Retrieved from h ps://www150.statcan.gc.ca/n1/daily-
quotidien/170913/dq170913a-eng.htm; Zussman, R. (2017). B.C. government set to
increase welfare rates and disability assistance. CBC News. Retrieved from
h p://www.cbc.ca/news/canada/british-columbia/b-c-government-set-to-increase-
welfare-rates-and-disability-assistance-1.4214828.
Thinking it Through
In 2016, the Health Status Survey (HSS) reported that individuals with
fewer ties to any community were among those aged 20–34.
1. What do you think are the reasons behind this feeling of not
belonging to any particular community?
2. Considering social support systems, how might a lower sense of
community ties impact this age group?
3. What other support systems do you think would be important here?
5 Social Environment
The social environment is constructed by how individuals behave; their
relationships with others and their community (including a person’s level
of a achment and social comfort regarding a feeling of belonging and
relationships); their gender, culture, and ethnic group; their education and
roles in the workforce; the conditions and communities in which they live;
and how they feel about themselves. These elements overlap with other
determinants to influence health and life expectancy. Individuals in the
same or similar social environments have been shown to demonstrate
similar values, outlook on life, and ways of thinking.
The tighter knit and more organized a community is, and the more
involved the population is with activities within the community, the
greater the health of that community. Keep in mind that the makeup of a
community and how it can impact the health of its population can vary.
For example, individuals or families living in a condominium may not
know their physical neighbours, but may be involved in a church or a
sports team. Remote communities, such as those in the northern parts of
Canada, are usually close-knit communities, but still lack access to a
variety of services and activities available in more populated regions. New
Canadians are subject to social isolation as they have left their families,
friends, and support networks behind and are trying to adapt to a new
culture.
Volunteerism promotes a sense of belonging and improves the well-
being of the social environment, apparently increasing a community’s
level of compassion, harmony, and cohesiveness. Volunteers themselves
generally live longer and suffer less from depression and heart disease
(Public Health Agency of Canada, n.d.).
Thinking it Through
You have an opportunity to volunteer at your community health centre.
You know it is a good cause but wonder if you can find the time with all
your other commitments at school and home.
6 Physical Environment
The physical environment consists of natural and manufactured
environments. The natural environment includes the food people eat, the
water they drink, the air they breathe, and the places they live—the
outside or physical world. The “manufactured” environment (also
referred to as the “built” environment) refers to the homes people live in,
the buildings where they a end school or work in, the roads they travel,
and the recreational areas such as parks and community structures they
use. How this built environment is structured and constructed affects
health status. For example, the phrase sick building or tight building
syndrome describes nonspecific illnesses that are a ributed to time spent in
a specific building. For example, Legionnaire disease is caused by bacteria
in the building’s ventilation system (Canadian Centre for Occupational
Health and Safety, 2017). Currently environmental issues are top of mind,
with widespread concern over drinking water and related infrastructure,
air pollution, environmental/global warming, pollution of agricultural
land, and depletion of natural resources.
Indigenous communities are particularly affected by problems with
drinking water and faulty water purification systems (e.g., failed water-
treatment plants, water towers). In November 2017, Health Canada
reported 130 drinking water advisories in effect in 85 Indigenous
communities (Government of Canada, 2017b). Building and maintaining
these structures is the responsibility of Indigenous and Northern Affairs
Canada.
Thinking it Through
As a student, you are likely faced with new challenges such as living
away from home, meeting new people, and dealing with academic
responsibilities.
Source: Shi, Y., de Groh, M., & Bancej, C., (2016). Socioeconomic gradients in
cardiovascular risk in Canadian children and adolescents. Health Promotion and
Chronic Disease Prevention in Canada: Research, Policy, and Practice. 36(2): 21–31.
Retrieved from h ps://www.canada.ca/content/dam/phac-aspc/migration/phac-
aspc/publicat/hpcdp-pspmc/36-2/assets/pdf/36-2-eng.pdf.
10 Health Services
Health services include diagnosis, treatment (both to maintain and restore
health), disease prevention, and health promotion—all pillars of the
population health and population health prevention approach. The type of
health care services offered and their method of delivery affect the health
of a population. Greater availability of primary care services and of health
promotion and disease prevention programs (e.g., immunizations,
preventive care such as breast screening, prenatal care, and well-baby
initiatives) can lead to a healthier population. Equally as important are
community and long-term care services. There are currently multiple
challenges facing health services in Canada such as financial, logistical,
and human health resources. Cost restraints affect prompt access to
diagnostic facilities, physicians, and procedures, and result in inadequate
staffing in hospitals (e.g., nurses). Isolated communities experience
inequities (such as access and treatment), and shortages of human health
resources remain (e.g., primary care providers, particularly in rural and
more isolated areas).
There are many other terms used to describe other identities as well. For
example, gender neutral or androgynous.
As a determinant of health, gender identity poses many challenges.
Acceptance or rejection by friends, families, and the community has a
profound effect on well-being. Employment may be hard to find because
of the stigma of being “different” in the eyes of the employer. The medical
community often fails to provide gender sensitive and appropriate care,
resulting in inequities related to the health care system itself. Additionally,
those transitioning from one sex to the other face long waits, emotionally
exhausting physical and mental assessments, and uncertainty as to what
procedures are covered under public health plans. The procedures
collectively are called sex reassignment or gender confirming surgery.
Criteria for coverage in most jurisdictions is based on standards
determined by the World Professional Association for Transgender Health
for gender dysphoria (discomfort and stress a person experiences when
their gender identity differs from their sex as assigned at birth). Surgery
required because of this diagnosis is considered to be medically necessary.
There are only two facilities in Canada doing genital surgery, one of which
is a private clinic in Montreal and the other in Toronto, through Women’s
College Hospital. Conditions for the surgery require the person to be in
good mental and physical health, and may require the person to take
hormones and live in their desired identity for at least a year.
12 Culture
Culture can be described as a way of life (e.g., behaviours, values,
a itudes, geographic and political factors) that is a ributed to a group of
people. Ethnicity refers more to race, origin or ancestry, identity, language,
and religion. Culture and ethnicity are often linked—and both affect
health, particularly in terms of health beliefs, health behaviours, and
lifestyle choices.
Those with different social, religious, value, and belief systems than
others in their community are more likely to face inequities,
marginalization, socioeconomic problems, and isolation. This may or may
not improve the longer an individual has been in Canada.
Minorities are especially at risk because the larger group’s
socioeconomic and cultural environments tend to dominate the
community, overshadowing needs of minorities. Risk factors for
minorities include health beliefs and health behaviours—for example, how
and at what point they will approach the health care system. Barriers to
seeking care may include fear, language struggles, and noninvolvement of
family members. Family members or friends/groups within a community
often provide significant support by contacting a physician, providing
transportation to the physician’s office or hospital, explaining the rationale
for treatments, and translating information when required.
Refugees arriving in Canada over the past 3 or 4 years (the majority of
whom have been granted residency upon arrival) have been sponsored by
either the government, individuals, or private groups. Those sponsored by
individuals or groups have more support adapting to life in Canada, as
their sponsors provide assistance with many aspects of rese lement
including finding and maintaining a suitable place to live, and connecting
to and understanding the health care system. Individuals who have spent
long periods of time in refugee camps may arrive with significant health
challenges requiring specialized care and dental care, which may or may
not be covered. In most cases, the government provides funding for a year.
Beyond that, if new Canadians don’t find employment, they rely on
provincial/territorial social assistance, which results in financial insecurity
—affecting all aspects of daily living.
Unemployment weighs heavily on the designated “bread-winner” in the
family and may impose feelings of inadequacies. Language can be a huge
barrier. For most refugees, access to learning English or French is provided
within a certain time frame, but a ending classes may be difficult. For
example, a family with small children may have to decide which parent
goes to these classes. Religion, dress, climate, rules and regulations,
community acceptance, and health care practices pose barriers related to
multiple health determinants.
Another group of people often overlooked are the refugees who have
arrived in Canada illegally and are awaiting immigration hearings, which
can take up to 2 years. Most have li le or no supportive networks, rely on
social assistance, and have no permanent place to live, relying on shelters,
or any space communities can provide. Large numbers choose to live in
larger centres where space is limited and budgets to support them are
strained. In terms of health determinants, these people are at risk mentally,
emotionally, and physically.
Thinking it Through
Over the past 2 years, Canada has accepted thousands of Syrians and
people from other countries. These “new Canadians” face many
challenges as they adjust to their new environment, from culture and
language to a aining financial independence and acceptance of who they
are.
1. Which determinants of health do you think are most likely to pose
challenges for these new Canadians?
2. How can communities best assist families who are sponsored by the
government?
3. What do you see as the most significant difficulties with respect to
health care?
The population health approach: the key elements
Implementing a population health approach to health care requires the
collaboration and cooperation of a number of agencies, organizations,
health professionals, policy makers, stakeholders, and volunteers, and in
which the Public Health Agency takes the lead role. Other important
partners include The Canadian Institute of Health Information, The
Canadian Institute for Health Research and Statistics Canada (see Chapter
2) supported by organizations at all levels of government and by
communities. Implementation of population health requires a formal plan,
which ensures that steps are executed in a coordinated manner, requires
that critical elements are identified, and that the role of agencies or
individuals is clearly defined. The Public Health Agency of Canada has
constructed eight key elements, which provide the framework for its
population health approach.
Thinking it Through
In Canada, it is widely recommended (with a few exceptions) that
everyone over the age of 6 months get an annual flu shot. Targeted or
high-risk groups (e.g., young children, older adults, individuals with
chronic diseases or compromised immune systems, and people working
in health care) are especially encouraged to get their flu vaccinations
early. The vaccine for the 2017–2018 season contained influenza A (H1N1)
virus, influenza A (H3N2) variant virus, and influenza B virus, but was
not particularly effective against some of the circulating strains,
prompting many not to get vaccinated. Researchers still recommend
ge ing vaccinated claiming that if contracted, the flu may be less severe
because of a phenomenon called cell mediated immunity (an immunity
built up over the years in vaccinated individuals). There were an average
number of adult deaths in Canada for that season, but more children
became sick, with several deaths, some confirmed to be from the B strain
of the virus (contained in this vaccine).
Box 6.5
An Aging Population: An Example of Population-
Based Surveillance.
Canada’s aging population is already stressing the health care system and
the economy. According to Statistics Canada (2017) the percentage of
older Canadians in the country accounts for 16.9% of the population, for
the first time exceeding the percentage of children (under the age of 14,
16.6%). If the pa ern continues, there will be 12 million older Canadians
and fewer than 8 million children by 2061. Because women live longer,
those over 65 will outnumber men aged over 65 by about 20%. Reasons
for a proportionately larger older population include the post–World War
II baby boom (1946–1965), increased longevity, and lower birth rates
(which started in the 1970s). Statistics Canada predicts that by 2056 older-
adult Canadians will account for 25–30% of the population. In terms of
demographics, this aging population has both social and economic
consequences (Statistics Canada, 2017). As older Canadians retire, fewer
young people are moving into the workforce. As well as affecting the
economy in general, this demographic shift will mean that fewer people
are working to support Canada’s social safety net, including seniors’
pensions and health care benefits. Possible solutions that the government
may consider include efforts to raise the birth rate and increase
immigration.
Source: Statistics Canada. (2017). Age and sex, and type of dwelling data: Key results from
the 2016 census. Retrieved from h ps://www150.statcan.gc.ca/n1/daily-
quotidien/170503/dq170503a-eng.htm.
Key Element 2. Address the Determinants of Health and
Their Interactions
Population health considers all of the factors (determinants) that affect
health of the target population. As outlined in Fig. 6.2, these determinants
are scrutinized in terms of how they interact with one another as well, and
indicators are selected. This information then forms the basis for
developing and implementing population health interventions.
Measuring and analyzing the determinants and how they are
interrelated is complicated. One determinant rarely stands alone as a
causative factor for a health problem. Consider diabetes that is associated
with obesity, and linked to poor nutrition and food insecurity.
LEARNING OUTCOMES
7.1 Discuss the key concepts of health, wellness, illness, disease, and
disability.
7.2 Explain the main models of health.
7.3 Discuss changing perceptions of health.
7.4 Examine the psychology of health behaviour.
7.5 Describe the wellness–illness continuum and the impact of self-
imposed risk behaviours.
7.6 Summarize the changing trends related to the leading causes of
morbidity and mortality in Canada.
KEY TERMS
Cardiovascular disease
Cerebrovascular disease
Compensation
Culture
Disability
Disease
Etiology
Exacerbation
Health behaviour
Health beliefs
Health model
Holistic
Indigenous peoples
Infant mortality
Life expectancy
Morbidity
Mortality
Remission
Self-imposed risk behaviours
Sick role behaviour
Signs
Symptoms
Wellness
Wellness–illness continuum
Health
What does it mean to be in good health? In the past the word health meant
a state of being, of sound mind, and generally suggested a wholeness of
the body—that the body was functioning well. Over time the concept of
mental health was integrated into the meaning. Thus an individual must
have both a healthy state of mind and physical well-being to be considered
in good health.
In 1948, the World Health Organization (WHO) took the important step
of acknowledging that health is multidimensional, and not merely the
presence or absence of disease. Although a vast improvement over
previous definitions, the WHO’s definition (Box 7.1) has not formally
changed since 1948 and remains largely out of step with current concepts
of health and wellness.
Box 7.1
Health: An Evolving Definition.
In 1948, the World Health Organization (WHO) originally defined health
as “a state of complete physical, mental, and social well-being and not
merely the absence of disease or infirmity.”
As perceptions of health evolved, components of this definition have
come into question. For instance, some suggested that the word complete is
unrealistic: How many people can claim to be completely healthy—and
what does completely healthy mean? The ambiguity of this term is
particularly evident today, with individuals living much longer with
chronic diseases such as diabetes and cardiovascular disease, as well as
those with physical disabilities and mental health challenges. Even some
forms of cancer are now considered a chronic condition. Accepting such
challenges has led individuals to consider themselves healthy within the
context of the health issues they are dealing with; their new “normal.”
This definition also fails to include holistic concepts, such as spiritual
wellness and cultural norms. Nurses, for example, must be aware of and
respect the spiritual and cultural needs of their patients (e.g., by ensuring
patients have access to religious or spiritual resources) when establishing
a nursing diagnosis and implementing nursing interventions.
Consequently, the WHO has expanded its concept of health adding to
its definition “the ability to identify and to realize aspirations, to satisfy
needs, and to change or cope with environment. Health is therefore a
resource for everyday life, not the objective of living. Health is a positive
concept emphasizing social and personal resources, as well as physical
capabilities” (World Health Organization, 1986).
Sources: World Health Organization. (1948). Preamble to the constitution of the World
Health Organization as adopted by the International Health Conference. New York; World
Health Organization. (1986). Health promotion: Concepts and principles in action—a
policy framework. Copenhagen: WHO Regional Office for Europe.
Wellness
Although wellness and health are often used interchangeably, the two
words are not synonymous; however, they share similar concepts.
Wellness goes beyond having good health. It considers how a person feels
about his or her health as well as his or her quality of life.
From a holistic perspective, to achieve wellness a person must take
responsibility for his or her own health by leading a balanced lifestyle and
avoiding self-imposed risk behaviours. The path toward wellness is not
static; it is continuous and must be a lifelong pursuit. Wellness develops
from the decisions people make about how to live their lives with quality,
good health (remember, good health is relative), and meaning.
Dimensions of Wellness
The concept of wellness embraces several categories including, but not
limited to, physical, emotional, intellectual, spiritual, and social health.
Some wellness models have more recently incorporated environmental
and occupational wellness. An even newer and emerging concept is family
wellness, which looks at each person in the family unit. If each person is
well, the family seems to do well. If a family member considers themselves
to be unwell, depending on numerous factors, the family unit, especially
relationships, may be adversely affected. A fine line exists between some
descriptions of these categories and how they are grouped; various
wellness models may divide or label them differently. It is worth noting
that some literature refers to the “dimensions of health” rather than the
“dimensions of wellness,” or the “wellness–illness” continuum rather than
the “health–illness” continuum, but are similar in that they consider more
than physical and mental health (Fig. 7.1).
Physical wellness
The dimension of physical wellness entails maintaining a healthy body by
eating a nutritious, balanced diet; exercising regularly; making intelligent,
informed decisions about one’s health; and seeking medical care when
necessary. People must understand how lifestyle choices affect physical
health to achieve physical wellness.
Mental wellness
The WHO defines mental health as “a state of well-being in which every
individual realizes his or her own potential, can cope with the normal
stresses of life, can work productively and fruitfully, and is able to make a
contribution to her or his community.” Mental wellness adds a holistic
dimension to the definition of mental health. It is being in relative
harmony with the dimensions of health and wellness. Mental wellness,
like physical wellness, is not static, nor does it mean the absence of mental
illness. A person with a diagnosed mental illness under treatment may feel
that they are coping well. Consider a person with bipolar disorder.
Someone who is bipolar can be well and controlled for long periods of
time with the proper interventions. A person with schizophrenia, who
responds well to treatment, may also consider themselves to be well most
of the time. A person may consider it a ma er of accepting their diagnosis
and all that goes with it—their new “normal.” Sometimes just knowing
what is wrong and being stabilized with treatment would move the person
to the wellness end of the continuum (discussed later in the chapter). For
many Indigenous people, mental wellness along with physical health
exists in balance with spirituality and nature, sometimes referred to as
Mother Earth.
Emotional wellness
Emotional wellness and mental health are often, but not necessarily,
interdependent entities. Emotional wellness includes people’s ability to
understand themselves, to recognize their strengths and limitations, and to
accept who they are. The emotionally adapted person effectively handles
and controls his or her emotions, communicates well, and seeks support
when needed.
Good mental health allows a person to react proactively when things go
wrong—to view adversity as an opportunity to learn and grow. Emotional
health very much contributes to this ability. Mental illnesses, such as
schizophrenia, bipolar disease, and depression, can affect a person’s
capacity to deal with situations effectively, especially when a situation
poses challenges or problems. Mental illnesses usually have a
physiological etiology (the origin or cause of a disease). An emotionally
well person can deal with reasonable stress—this is more difficult for most
in the presence of a mental illness. Remember that everything is relative,
no situation is the same, nor are people’s reactions despite the presence or
absence of emotional health, mental health, or mental illness.
Intellectual wellness
Intellectual wellness reflects people’s ability to make informed decisions
that are appropriate for and beneficial to themselves. From their
experiences and learnings, intellectually well people are able to gather
information throughout their lifespan and to use that information to make
the best of situations. Moreover, these people apply critical thinking skills,
prioritize data, and keep informed on current health research, treatments,
and health-related issues.
Intellectual wellness may also include occupational health—personal
satisfaction from one’s career and the ability to balance career with other
activities like family and leisure time.
Thinking it Through
Spirituality has been linked to good health and wellness, with reported
benefits ranging from fewer health issues, including anxiety and
depression, to a faster recovery. Many people also claim that spirituality
provides them with an enhanced ability to deal with stress.
1. What does spirituality mean to you?
2. Why do you think spirituality may contribute to be er health?
3. How would you respond to a patient who told you that he or she
wanted to try self-healing through spiritual practice instead of
accepting medical intervention for a diagnosed medical condition?
Social wellness
Social wellness is about relating effectively to others, including being able
to form close, loving relationships, to laugh, to communicate effectively
and empathically, to be a good listener, and to respond appropriately.
Socially well individuals work agreeably in groups and within the
community, are tolerant and accepting of others, and can form friendships
and supportive networks. Confident and flexible, socially well people
contribute to the welfare of others.
Spiritual wellness
Spiritual wellness is different for most people, and entirely personal. It
frequently involves a search for, or achievement of, a sense of purpose or
meaning in their lives. It may be based on a faith of some kind, or religion,
or encompass a search for harmony and balance with life, themselves, and
others. It may encompass a sense of balance—connecting various
components of the person’s life—achieving a feeling of productiveness
and inner peace. Achieving spiritual wellness can involve prayer,
meditation, or other spiritual practices. A aining spiritual wellness may
afford a person peace, joy, a purpose in life, and the ability to relate to
others in a positive, kind, and meaningful way. Spirituality is an important
part of the Indigenous culture and congruent with a holistic approach to
personhood, health, and wellness. The spiritually well person often seeks
to contribute to society, plays an active role within the community, and
displays gratitude and generosity.
Environmental wellness
Newer models of wellness take into account one’s relationship with the
environment (environmental wellness). An environmentally well person is
one who engages in a lifestyle that is friendly to the environment.
Friendliness to the environment entails consciousness about preserving
the external world, such as walking or biking (instead of driving),
recycling, choosing products that are less harmful to the environment (e.g.,
less packaging). It may also include creating a safe internal environment;
for example, by protecting one’s eyesight (e.g., using good lighting when
reading or working), or limiting loud noises (e.g., controlling music
volume).
Occupational wellness
Occupational wellness occurs when a person feels secure, confident, and
valued in his or her workplace se ing. Occupationally well people manage
work-related stress effectively, grow professionally, and balance the
demands of their job with their personal lives. The level of enjoyment
people have with their job affects most aspects of their lives—and those of
the people around them.
Illness
The term illness, often used to denote the presence of disease, can also refer
to how a person feels about his or her health, whether or not a disease is
present. Despite the absence of pathology or disease, a person may feel ill
as a result of tiredness, stress, or both. Although this state differs from
feeling healthy and energetic, by definition, it is not a disease.
Disease
Disease typically refers to a condition in which a person’s bodily or mental
functions are different from normal. Usually biological in nature, disease
may affect various organs of the body and have symptoms that are either
observable or difficult to detect. Causes of diseases include the presence of
organisms such as bacteria, a virus, or a fungus. Schizophrenia is an
example of a disease in which mental functions are affected, resulting in
behavioural or psychological alterations, and has a biological or
biochemical explanation.
The term disease may be also be used to describe a group of symptoms
(more accurately called a syndrome), which are not related to a clear-cut
disease process. Disease is often used interchangeably with the vague
words: ailment, disorder, condition, or dysfunction. Disease is also sometimes
used incorrectly to refer to a disability.
A disease may run a predictable course and subside—with or without
treatment (e.g., pneumonia or influenza), or it may be chronic and
controllable, but not curable (e.g., asthma, diabetes, human
immunodeficiency virus [HIV], acquired immune deficiency syndrome
[AIDS]). Other diseases are long term and have symptoms that disappear
and recur (i.e., go into a period of remission). This reappearance of
symptoms and reactivation of the disease is known as an exacerbation of
the disease (e.g., as happens with multiple sclerosis).
Remission of a disease can occur spontaneously or be induced by
treatment. In the case of multiple sclerosis, for example, the use of
immunosuppressive medications can result in a treatment-related
remission. A remission’s length varies. The main aim of treatment for
leukemia is a complete remission—that is, no signs of the disease from a
symptomatic or pathological perspective. If a remission lasts more than 5
years, some consider the person to be cured. In the case of any kind of
cancer, however, the word cure is used cautiously; some physicians avoid
ever saying a person is cured, regardless of the length of time he or she has
been cancer free.
Thinking it Through
Suppose you had a chronic condition such as multiple sclerosis, but were
managing reasonably well most of the time, for instance, if your multiple
sclerosis (MS) was in a period of remission. Reflecting on your own
definition of wellness, answer the following:
1. Do you think you would consider yourself to be well?
2. Do you think your outlook would by influenced by periods of
remission or exacerbation of the condition?
3. Answer the first two questions considering two chronic diseases that
people you know may have.
Disability
A deviation from normal function, a disability can be physical, sensory
(e.g., blindness, deafness), cognitive (e.g., Alzheimer’s disease), or
intellectual (e.g., Down syndrome). A disability can occur in conjunction
with, or as a result of, a disease (e.g., a person with diabetes may undergo
amputation of part of a leg because of impaired circulation); be caused by
an accident; or be present at birth, either as a result of genetics or due to
complications during delivery (e.g., an absence of a limb, cerebral palsy,
spina bifida).
The language used to describe people with a disability has changed over
the years, moving toward more sensitive, less hurtful terminology. For
example, today, a person with a cognitive or intellectual disability is most
likely to be deemed intellectually impaired. Along with improved
terminology has come the recognition that people with disabilities deserve
the same rights and opportunities as all other members of society.
Individuals with disabilities still face a degree of ableism; others are often
impatient with and dismissive of individuals with either cognitive or
physical limitations. Invisible disabilities can face similar challenges (Box
7.2).
Box 7.2
People With Disabilities: Rights Are Formally
Recognized.
Historically, people with disabilities have been viewed as individuals who
need societal protection, evoking sympathy rather than respect. In an
effort to change this perception and to ensure that all people have the
opportunity to live life to their fullest potential, December 2016 marked
the tenth anniversary of the United Nations formally adopting the
Convention on the Rights of Persons With Disabilities. This was the first such
inclusive human rights treaty of this century. The convention covers a
number of key areas, including accessibility, personal mobility, health
care, education, employment, rehabilitation, participation in political life,
equality, and nondiscrimination. All jurisdictions have acts or other pieces
of legislation to protect people with disabilities, and almost all are
constantly being improved. After consultation with all jurisdictions
including Indigenous peoples and individuals with disabilities, Canada
ratified this Convention in 2010 and is bound to it by international law.
In 2015, the UN’s initiative “Transforming our world: the 2030 Agenda
for Sustainable Development” maintained a commitment to ensure that
people with disabilities and other vulnerable populations are specifically
included in all of the Agenda’s goals. These goals are broad and include,
for example, people, planet, prosperity, peace, and partnership; each has a
clearly defined target intended to stimulate defined actions over the next
15 or so years. The statement related to People for example states, “we are
determined to end poverty and hunger, in all their forms and dimensions,
and to ensure that all human beings can fulfil their potential in dignity
and equality and in a healthy environment” (United Nations, 2015).
In Canada, federal legislation protecting people with disabilities
includes the Canadian Charter of Rights and Freedoms, Canadian Human
Rights Act, and the Rights of People with Disabilities.
Medical Model
The medical model was founded on a simple definition: health is the
absence of disease. More recently, this model has expanded to consider
aspects of functioning, disability, and limitation of activity, and the ability
to perform the activities of daily living, thus accepting that a person with
physical limitations may nevertheless be healthy.
In the twenty-first century, critics of the medical model argue that the
model’s scope is too narrow and that the presence or absence of disease
alone does not define one’s health. This model does not consider social
causes of disease that are beyond an individual’s control (e.g., disparities
in socioeconomic status and education). By emphasizing the diagnosis and
treatment of disease, the medical model ignores the role of prevention—
efforts to stop disease and disability before they occur (Larson, 1991).
Holistic Model
The holistic approach to health considers all parts of the person. This
approach has been used for many years’ time by alternative practitioners,
such as naturopaths; only recently has it been integrated into mainstream
medicine.
Focusing on the positive aspects of health—not on the negatives of
illness and disease that inform the medical model—the holistic model
strives for a state of health that encompasses the entire person, rather than
just aiming for a lack of disease and disability. Although similar to the
original WHO definition of health introduced in 1948 (see Box 7.1), the
holistic definition of health goes much further by recognizing the impact of
factors such as lifestyle, spirituality, socioeconomics, and culture on an
individual’s health.
Although initially described as “utopian” (i.e., impossible to achieve),
the holistic model has become widely accepted as a be er alternative to
the medical model (Larson, 1991).
Thinking it Through
There are many other definitions of health. Consider some of the WHO’s
international classification systems such as the International Classification
of Functioning, Disability (which measures the relationship between
health and disabilities at an individual and population level). These
systems are sometimes used in developing current concepts of how health
should be defined. The WHO definition does not clearly address
individuals with disabilities. Can someone with a spinal cord injury not
consider him or herself to be healthy? Can individuals who participate in
the Special Olympics or the Invictus Games not consider themselves
healthy? Participants cope with physical as well as mental challenges and
show remarkable strength, courage, and perseverance as they achieve
their goals. Can anyone really define health in terms that would suit
everyone, or is it individual? What would you consider to be a realistic,
inclusive definition of health study?
Past Approaches
Until the early-to-mid 1960s, most Canadians held the a itude that if they
were sick they would seek medical care, and the doctor would make them
be er. People took li le responsibility for their own health and rarely
participated in decisions related to their treatment. They did what the
doctor told them to do and most doctors did not expect to be questioned.
Doctors and patients functioned very much within the realm of a
paternalistic medical model. Few people recognized the impact of lifestyle
on their health and safety. Engaging in self-imposed risk behaviours, such
as a sedentary lifestyle, poor nutritional habits, smoking, and alcohol
abuse, was rarely directly linked to changes in health status. Within the
medical community there was limited education related to promoting a
healthy lifestyle. This approach began to change in the 1960s and 1970s.
With the help of government initiatives and the establishment of a
population health approach to health care (see Chapter 6), Canadians
started to see the value of prevention and to consider what they could do
on a personal level to stay healthy—that is, they began to take more
responsibility for their own well-being. Slowly, community and group
involvement in health promotion and disease prevention emerged.
The 1980s and 1990s saw the beginning of changes in the structure and
function of how primary care was delivered further encouraging
individuals to not only take responsibility for their own health, but to
participate in making decisions about their treatment, which is the norm
today. Canadians are now more informed, sometimes looking up pertinent
information on the internet and bringing it in to their health care provider.
Although some information is accurate, some is not; this can have
harmful consequences promoting anxiety and stress. Sometimes providers
are overwhelmed with the amount of intimation presented to them by
their patients. On the whole, people have become self-advocates, seeking
answers if they are not satisfied with what they have been told, perhaps
asking for a second opinion. There are also more choices available.
Currently most primary care groups offer a team of health professionals
for the patient to access that can include a nurse practitioner, dietician, or a
counsellor. Individuals are more likely to seek out alternative modalities
for treating ailments—anxiety, stress, various diseases, and physical
problems. Increasingly (though not always), physicians are happy to work
with alternative practitioners, offering their patients the best of both
worlds.
Public education regarding lifestyle changes continues to have at least a
moderate effect. A federal public initiative, aptly called ParticipACTION,
launched in 1971, still promotes a healthy lifestyle through increased
physical activity. ParticipACTION has evolved into a network of both
public sector and nongovernment organizations (NGOs), whose goals are
to promote physical activity, including participation in sports activities.
Other organizations do their bit to encourage a healthy lifestyle. The Heart
and Stroke Association, for example, sponsors riveting commercials on
lifestyle choices (e.g., smoking, inactivity) and related risks. Antismoking
campaigns along with related legislation (including laws governing
electronic cigare es, see Chapter 8). Similarly, ongoing campaigns (such as
Mothers Against Drunk Drivers [MADD]) and laws against drinking and
driving continue to reinforce the risks and push for the reduction of
alcohol consumption. Now, with the implementation of the legalization of
marijuana, new challenges are posed in terms of health and safety (see
Chapter 8). Canadians, on the whole, pay a ention to information being
offered and are supportive of related legislation, recognizing that
prevention goes a long way. Today Canadians have a much broader-based
understanding of the link between lifestyle and health. Most people
recognize that smoking causes lung cancer and respiratory disease. And
g g g p y
many know that being active can lower their chances of developing high
blood pressure, osteoporosis, cardiovascular disease, and even some types
of cancer. People are more aware than ever before that there is a link
between obesity, inactivity, and diabetes. Obviously, how individuals
respond to this knowledge depends on how they view health, wellness,
and their own vulnerability. Still, much work remains to be done.
Thinking it Through
A close friend of yours, a very heavy smoker (two packs of cigare es
daily), is diagnosed with high blood pressure and has a family history of
cancer. In spite of being aware of his history and the related risks, he
refuses to stop smoking, stating, “It’s my life, and I love to smoke.” You
believe that he does not comprehend the consequences of his habit and
feel very strongly that he should quit. How might you influence his
decision—or would you try?
The psychology of health behaviour
Demonstrated by a person’s response or reaction to altered health, health
behaviour has a significant impact on what a person does to maintain
good physical and psychological health. Many factors, including what a
person believes to be true about health, prevention, treatment, and
vulnerability, influence how people act when they are ill or perceive they
are ill. Health behaviour also depends on a person’s level of health
knowledge, personal motivation, cognitive processes, and perceived risk
factors. One’s culture and ethnicity will invariably affect all of these areas.
To explain human health behaviour, several models have been
developed, including the transtheoretical model, the social–ecological
model, the protection motivation theory, and the health belief model
(developed in the 1950s by the United States Public Health Service).
Elements of the health belief model are relevant in one way or another to
all of the other models, so it is described in detail below.
Transtheoretical Model
The transtheoretical model (TTM) of health behaviour is a framework for
promoting adaptive changes in a person’s health behaviour. The concept
proposes that people must progress through the following series of steps
before their health behaviour completely changes (i.e., improves):
precontemplation, contemplation, preparation, action, maintenance, and
termination. Integrated into these steps are ten cognitive and behavioural
activities that further facilitate change. For example, during the
precontemplation stage, although aware that a behaviour modification
may improve his or her health, the person may initially have no desire or
motivation to make a change. During the contemplation stage, the person
is ready to seriously think about making changes and may consider the
risks and benefits of a behaviour change. The action phase is when the
person implements his or her plan like going to the gym—perhaps
engaging a personal trainer, or preparing and eating a healthy meal. The
ongoing support of others is important during this phase. If the person is
able to adhere to their plan for at least 6 months they are ready to move
into the maintenance phase, which must continue for 2 years—continuing
with an exercise program and eating a balanced diet. Once achieved, the
individual enters into the termination phase. At this point the person’s
behavioural changes are integrated into their lifestyle and considered
permanent.
Social–Ecological Model
The social–ecological model (SEM) maintains that many levels of influence
shape health behaviour, with a focus on health promotion for individuals
as well as groups of people within organizations. Such influences include a
person’s education, occupation, or profession; the type of social support
(personal, community) he or she has; his or her environment (e.g.,
workplace, availability of health care); and the public policies of various
levels of government. SEM considers how various entities that put people
at risk for developing health, behavioural and socioeconomic problems
citing individual, relationship, community, and societal factors.
Recognizing that there is an interplay between multiple factors promotes
an understanding that one affects another (Centers for Disease Control
and Prevention, 2017).
The ideal situation is one wherein the determinants of health are the
foundation for policy development collectively promoting good health,
health education, and a healthy workplace.
Source: CBC News. (2017, April 20). Nicole Ireland. 1,300 Canadians have died with
medical assistance since legalization—here’s one man’s story. Retrieved from
www.cbc.ca/news/health/medically-assisted-dying-canadians-rob-rollins-1.4056700.
Notes: Life expectancies are calculated with a method that uses 3 years of data.
Sources: Statistics Canada. (2018). Life expectancy and other elements of the life table,
Canada, all provinces except Prince Edward Island. Table: 13-10-0114-01. Retrieved from
h ps://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310011401; Statistics Canada.
(2018). Life expectancy and other elements of the life table, Prince Edward Island and the
Territories. Table: 13-10-0140-01. Retrieved from
h ps://www150.statcan.gc.ca/t1/tbl1/en/tv.action?
pid=1310014001&pickMembers%5B0%5D=1.4&pickMembers%5B1%5D=3.3&pickMe
mbers%5B2%5D=4.8.
Source: CBC News. (2012). Canada’s rank on infant mortality index called unfair.
CBC. Retrieved from h p://www.cbc.ca/news/health/story/2012/02/17/health-infant-
mortality-study.html.
Cancer
One in two Canadians are expected to develop cancer in their lifetime,
with slightly higher rates among women—most over the age of fifty
(Canadian Cancer Society, 2017). Lung, breast, colorectal, and prostate are
the most common types of cancer in Canada (Canadian Cancer Society
2017). There are various causes of cancer. The incidence of different types
of cancer is influenced by such things as risk behaviour (smoking),
environment factors (pollution), socioeconomic factors (poverty), lack of
education related to disease prevention and health promotion, and access
to cancer medical services such as cancer screening. These factors affect the
number of cases and types of cancer seen across the country (e.g., What
cancers are seen more frequently in some regions and not in others?).
British Columbia, Alberta, Ontario, and Saskatchewan have the lowest
rates of cancer, whereas Newfoundland and Labrador, Northwest
Territories (NWT), Yukon, and Nunavut have the highest rates. This is
likely impacted, in part, by geographic isolation, which may contribute to
unemployment and even poverty, accessible medical services, and other
elements negatively affecting the determinants of health. It is interesting to
note that although Newfoundland and Labrador has one of the highest
rates of all cancers, it has the lowest rate of breast cancer among all
provinces and territories (Conference Board of Canada, 2015).
While the incidence of some types of cancers have decreased (e.g., throat
and stomach), others (e.g., breast cancer) have seen a moderate increase
and some (e.g., liver and thyroid) have seen significant increases. Breast
cancer is the second leading cause of death in Canadian women,
responsible for 25% of all cancers. In 2017, on average 72 women were
diagnosed with breast cancer daily, and an estimated 14 deaths each day.
While the incidence of breast cancer is up slightly, there are fewer deaths
because of early detection, and more effective treatments (Canadian
Cancer Society, 2018).
In Canada, prostate cancer is the most common type of cancer among
men, responsible for an estimated 21% of all cancer diagnosis in 2017. The
Canadian Cancer Society estimates one in seven men were diagnosed with
prostate cancer in 2017, and 1 in 29 died from it.
Mortality rates for prostate cancer are relatively low because of early
diagnosis, treatment when indicated, and because most prostate cancers
are slow growing. Because of the low mortality rates, there is controversy
over how aggressively to screen for and treat diagnosed cases of prostate
cancer. The age of the individual is a factor in treatment. Monitoring the
progress of prostate cancer is achieved through periodic assessments of
the person’s prostate-specific antigen (PSA) levels. Most jurisdictions (e.g.,
Ontario and British Columbia) will cover the cost of a PSA test if
recommended by a health care provider for monitoring purposes. The cost
is not covered for routine screening in most jurisdictions—a person can
request the test but will have to pay out of pocket (according to the 2017
fee schedule in Saskatchewan this would cost $54.85) (Prostate Cancer
Canada, 2014). Lung cancer remains the leading cause of all cancer-related
deaths in both males and females, with an estimated 28,600 new cases
diagnosed in 2017, and 21,100 deaths the same year (Public Health Agency
of Canada, 2017). The incidence of lung cancer is higher in males than in
females.
From a global perspective, according to the World Cancer Research
Fund International (2017), Puerto Rico has the lowest rate of all age-related
g
cancers and Denmark has the highest. (Canada has the 12th highest rate
out of 50 countries.)
Cardiovascular Diseases
Cardiovascular disease (CVD)—also referred to as ischemic heart disease
—is the second leading cause of death in Canada and responsible for 29%
of all deaths (Government of Canada 2017). Cardiovascular diseases
include coronary artery disease (CAD), congestive heart failure, arrhythmia
(abnormal heartbeat), and peripheral vascular disease (problems with
circulation, primarily in the legs). Of these, CAD is the most common.
Primary risk factors for developing heart disease include smoking, high
blood pressure, high cholesterol, inactivity, and obesity. Genetics are also a
contributing factor. The incidence of heart disease has decreased slightly
over the past few years, likely because of improved screening (and
treatment) for risk factors, education related to health promotion and
disease prevention (risk reduction), and lifestyle changes.
An estimated one in 12 Canadians over the age of 20 is living with some
form of heart disease. Mortality rates increase with age. Men are more
than twice as likely to develop heart disease even though men are typically
diagnosed on average 10 years younger than women. Indigenous
Canadians are approximately twice as likely to develop heart disease,
particularly those who live on-reserve and are subject to a wide range of
cardiovascular risk factors including food insecurity, obesity, and
inactivity.
Generally, population health initiatives implemented by both federal
and provincial/territorial governments have contributed to lower mortality
rates from heart disease and a healthier lifestyle. Other organizations such
as the Heart and Stroke Foundation and the Canadian Society for Exercise
Physiology also encourage an active lifestyle. ParticipACTION’s 2016
Report Card on Physical Activity for Children and Youth also addresses the
importance of adequate rest (combined with activity). Based on this report,
ParticipACTION Canada developed the world’s first 24-Hour Movement
Guidelines (ParticipACTION, 2016). With heart health in mind, the
organization has also recently introduced regulations forcing
manufacturers to lower the amount of trans fats in prepared foods,
launched public campaigns to encourage manufacturers to lower sodium
content in foods, and made efforts to reduce the sale of unhealthy foods in
schools.
Cerebrovascular Disease
Cerebrovascular disease includes a number of conditions that affect the
flow of blood to the brain, the most serious of which is stroke. Stroke
occurs when there is a blockage of oxygen to part of the brain, which is
caused by an interruption in the blood flow, most commonly a blood clot.
Stroke is the leading cause of adult disability, the third leading cause of
death, and is more common in women than men (Statistics Canada, 2013).
Nine in ten Canadians have at least one risk factor for stroke; the risk
factors are the same as those for heart disease (Heart and Stroke
Foundation, 2017).
Heart disease and stroke together are also the leading causes of
hospitalization in Canada, and according to the Conference Board of
Canada, cost the Canadian economy $20.9 billion/year (Heart and Stroke
Foundation, 2014). Nunavut (which is puzzling given the risk factors in
that jurisdiction) and Quebec have the lowest mortality rates from heart
disease and stroke, while Labrador and Newfoundland and the NWT have
the highest (Conference Board of Canada, 2018). A 2013 report on the
health of Canadians sponsored by the Canadian Heart and Stroke
Association claims that without immediate action, older Canadians
(mostly baby boomers) will spend the last 10 years of their lives living
with illness, disability, and mobility problems (Heart and Stroke
Foundation, 2013b). Supporting this, Stats Canada reports that there is a
gap “between how long we live, and how long we live in health” (Heart
and Stroke Foundation, 2013a). One can only assume from these facts, the
message that we Canadians can do much to reduce our risk factors for
acquiring a variety of infirmities, including stroke and heart disease, is
somehow not ge ing through, even though access to health information
and teaching materials has been greatly enhanced by the Internet. More
work is clearly needed to teach Canadians that adopting a healthy lifestyle
at an early age will increase the chances of enjoying be er health in one’s
later years.
Summary
7.1 Today, the key concepts of health, wellness, and illness are
defined in less black-and-white terms. Definitions of health relate
to such things as an individual’s own culture, background, and
experiences. Wellness goes beyond having good physical and
mental health and considers how a person feels about his or her
health and quality of life. The many dimensions of wellness
include physical, emotional, intellectual, spiritual, social,
environmental, and occupational health. Disease refers to a
condition in which a person’s mental or bodily functions are
different from normal. The term illness, often used to denote the
presence of disease, can also refer to how a person feels about his
or her health, whether or not a disease is present. A disability can
be physical, sensory, cognitive, or intellectual and can occur in
conjunction with or as a result of a disease, or be caused by an
accident.
7.2 How health care is delivered is reflected in a design, a philosophy,
and an approach. Three approaches, or models, are most
frequently used: the medical, holistic, and wellness models. The
(w)holistic framework is an approach to health used by many
Indigenous people, and is based on the circle, the medicine wheel,
and the four directions of east, west, south, and north. Some people
prefer a natural approach to health care—noninvasive, leaning
away from mainstream diagnosis and intervention. Others have
more faith in proven treatments. Still others will blend
philosophies.
7.3 Several factors influence how people respond when their health is
compromised. These include past experiences and one’s outlook on
life (e.g., optimistic, pessimistic). Over the past several years,
Canadians, for the most part, have assumed more responsibility for
their own health, assessing their own risk behaviours and focusing
on health promotion and disease prevention.
7.4 Health behaviour is how a person responds to all aspects of
altered health. How they react affects their relationship with health
care providers, family members, and others close to them. A
person’s response to an altered health situation is unique to each
person and influenced by his or her background, social and
cultural beliefs, and past experiences with the health care system.
Understanding that deviations from a person’s normal behaviour
are just that—and supporting him or her appropriately—will go a
long way to helping a patient recover.
7.5 By some standards, such as the health–illness continuum, a
person’s health is measurable. How a person feels about his or her
health changes frequently and is influenced by the type and
severity of an infirmity, personal health beliefs, and the health
model the person most closely relates to.
7.6 Overall, the health of Canadians has improved over the past
decade, yet challenges remain in providing prompt and effective
care, particularly for those with cancer, cardiovascular diseases,
and diseases of the respiratory system—the leading causes of
morbidity and mortality in the country. Aboriginal peoples are
particularly at risk for socioeconomic reasons, and for many,
because of the lack of proximity to larger treatment centres.
Review questions
Describe the dimensions of wellness, and explain how wellness goes
beyond having good health.
LEARNING OUTCOMES
Key terms
Act
Civil law
Code of ethics
Common law
Confidentiality
Conflict of interest
Constitutional law
Contract law
Controlled Drugs and Substances Act
Criminal law
Duty of care
Electronic health record (EHR)
Electronic medical record (EMR)
Fiduciary duty
Good Samaritan law
Implied consent
Incident report
Informed consent
Malpractice
Negligence
Oral consent
Personal Information Protection and Electronic Documents Act
(PIPEDA)
Power of a orney
Privacy
Professional misconduct
Quarantine Act
Regulation
Regulatory law
Statutory law
Tort
Whistleblower
Workplace Hazardous Materials Information System (WHMIS)
legislation
This chapter is not meant to replace a separate legal course you may
take in your program, but rather provides a practical overview of the
relationship between the law and some elements of health care in
Canada. It concentrates on selected basic elements of health care and
the application of related legal issues, rather than on specific laws
and legislation. Because laws vary among the provinces and
territories, it is more meaningful for students to research those
within their own jurisdiction to access specific information.
Most health care providers, health care facilities, regional health
and other governing authorities, and regulated professions are
governed by legislation, regulations, or guidelines, which affect how
they function. This chapter begins by examining the division of
legislative powers between the Federal Government and the
provincial and territorial governments where health care is
concerned. It also discusses the legal responsibilities of the Federal
Government with respect to safety legislation and sections within
criminal law that affect health care.
This chapter also looks at the legal rights of Canadians to health
care under the Canada Health Act, the law according to the Charter
of Rights and Freedoms.
Private enterprise in health care is growing across the country
often clashing with the principles of publicly funded health care, and
legislation regarding private enterprise varies among jurisdictions.
Many Canadians embrace the chance to choose between public and
private services, others do not. This chapter briefly discusses
restrictions imposed on Canadians with regard to seeking health
care from private clinics and the right of Canadians to purchase
private insurance for medically necessary services that the provinces
or territories cannot provide within reasonable time frames.
Other topics discussed include the legal guidelines and
responsibilities of health care providers regarding consent to
treatment, and how to mediate requests for medical assistance in
dying. The effects of the law on health care providers, as well as on
their moral and legal obligations to patients, are also highlighted.
Finally, this chapter addresses health information management,
confidentiality, and current privacy legislation—and the challenges
presented by electronic health records.
Laws used in health care legislation
Laws in Canada include both statutory law (i.e., derived from acts)
and common law (i.e., made by judges in deciding cases). Various
levels of government are authorized to create laws. Some laws apply
to the health care industry more than others, including
constitutional, statutory, regulatory, and common (or case) law, all
of which are described in the sections that follow.
Constitutional Law
Constitutional law addresses the relationship between the people
and their government, and establishes, allocates, and limits public
power. In Canada, cases challenging a person’s right to health care
have been based on the Canadian Charter of Rights and Freedoms,
part of the Canadian Constitution. Under the Constitution, everyone
has the following fundamental freedoms (Canadian Charter of
Rights and Freedoms, 1982):
Statutory Law
A statute is a law or an act. Statutory laws are the laws passed in
Parliament (i.e., at the federal level) or in the provincial or territorial
legislatures. Examples of statutory laws under federal authority
include those dealing with immigration, taxation, and divorce.
Statutory laws under provincial or territorial jurisdiction include
those related to education, family, and health care.
Regulatory Law
Regulatory law, also referred to as subordinate legislation, is a form of
law that possesses the legally binding feature of an act, because it is
usually made under the authority of an Act. Although regulatory
law may be left to government departments and agencies to
complete, regulatory law is not made by Parliament (i.e., at the
federal level) or by provincial or territorial legislatures but rather by
delegated persons or organizations, such as an administrative
agency or a tribunal. The authority to implement regulations,
however, must be specifically outlined in a federal, provincial, or
territorial act—for example, in Manitoba, the Regional Health
Authorities Act gives regional health authorities the power to make,
implement, and enforce regulations. Federally the Food and Drugs
Act oversees Health Canada’s Food and Drug Regulations.
In health care, regulatory law affects hospital boards, health care
institutions, and bodies governing health care providers. Under
provincial and territorial health care professions acts (e.g., Ontario’s
Regulated Health Professions Act), the Minister of Health oversees the
manner in which health care professions operate and govern
themselves and also retains the power to request that a council
make, amend, or revoke a particular regulation.
Box 8.1
Equality of Care for Hearing Impaired People.
Linda and John Warren, and John Eldridge were born deaf. For
many years, a private, nonprofit organization provided sign
interpreters to help them communicate with health care providers
during doctors’ appointments, hospital visits, medical tests, and the
like. Sign language was their preferred method of communication.
In 1990, because of funding shortfalls, the organization that had
provided the interpreter discontinued this service. Several appeals
for financing proved futile, and the trio was left with no support to
hire an interpreter. They claimed that the absence of a sign
interpreter interfered with their ability to effectively communicate
with health care providers, increasing the opportunity for errors in
diagnosis and treatment and impeding their ability to understand
treatment options and to make informed decisions. Requests to the
provincial and federal governments for support were repeatedly
denied.
After a long legal ba le ending at the Supreme Court of Canada,
the Court ruled that the Hospital Services Act and the Medical and
Health Care Services Act contravened section 15(1) of the Charter
(equality rights) by failing to address the need for services for
individuals to communicate effectively with health care providers.
The Supreme Court directed that both acts—as well as those of
other provinces and territories—be changed to accommodate these
rights.
Tort Law
A tort occurs when one person or that person’s property is wronged
or harmed by another, either intentionally (deliberately) or
unintentionally. Tort law cases can be complicated—for example,
proving negligence over an intentional act.
Intentional tort
An intentional tort occurs when the harmful act is deliberate. In
health care, it usually involves physical aggression or forcing
unwanted medical treatment on a patient. Two examples of an
intentional tort are: a health care aide was proven to have treated a
patient roughly, resulting in injury to that patient, or if a health care
provider successfully performed cardiopulmonary resuscitation
(CPR) on an individual who had a known do-not-resuscitate order.
Unintentional tort
An unintentional tort occurs when the act caused physical or
emotional injury or property damage, but was not deliberate or
calculated. Unintentional torts usually result from acts of human
error, misjudgment, or negligence. For example, human error might
be considered the cause if a respiratory therapist gave an inhalation
treatment to a child and mistakenly used the wrong drug. A
physiotherapist might misjudge a patient’s ability to ambulate,
resulting in a fall the first time they tried to get up independently.
Negligence is one of the most common torts, and cases are often
complicated.
Negligence
Negligence is the same is a type of tort law. Negligence can be in the
form of malpractice, or depending on the case, professional
misconduct. Negligence occurs when a health care provider
(unintentionally) fails to meet the standards of care required of his or
her profession. Negligence can occur when a duty of care owed a
person is not completed. In health care, examples may include
forge ing to perform a necessary action, not caring or confirming
whether a particular and necessary action is performed, providing
improper or substandard care, providing a patient with unclear
instructions, or failing to successfully instruct a patient in how to
follow a treatment plan (Case Example 8.1).
Contract Law
Contract law involves private agreements that are generally
enforceable by the courts like many other laws, provided the
agreement does not violate other governing laws or is otherwise
illegal in purpose. For example, contracts can exist between an
employer and an employee, or a health care provider and a patient.
They also may be either expressed (i.e., openly spoken or wri en) or
implied (i.e., unspoken but considered understood).
A breach of contract occurs when one of the parties fails to meet
the terms of the agreement. A plastic surgeon, for example, can
agree to perform a facelift on a patient for a given price. If, for some
reason, the physician fails to complete the procedure, or if the
patient refuses to pay the agreed-upon price, one can sue the other
for breach of contract. Another example: a private health care
organization hires a dentist on a one-year contract. After two
months, the dentist finds a higher-paying position and leaves. The
health care organization can sue the dentist for breach of contract.
Criminal Law
In Canada, criminal law, with a few exceptions, is set out in federal
legislation. Most laws can be found in the Criminal Code of Canada,
which details descriptions of crimes and criminal law procedures. It
is a category of public law that deals with crimes against people
and/or property and those deemed intolerable with society (e.g.,
murder, racism, theft). In most cases to be guilty of a crime a person
must perform a wrongful act—actus reus (what was done) and a
wrongful intent—mens rea (a guilty mind). For example, a health care
practitioner who willfully engages in a harmful act with the intent of
harming his or her patient.
Criminal charges involving health professionals and patients
consider the “duty of care,” the principle of “do no harm,” and a
health professional’s degree of authority, which would be
considered in tort liability and could impact sentencing in criminal
cases. Unless the law specifically imposes special duties of care, the
law is the same for all.
Although an extreme case, consider the nurse Elizabeth
We laufer, who pleaded guilty, among other charges, to killing eight
older Canadians in nursing homes in London and Woodstock,
Ontario in 2016. She was in a position of authority, her patients were
vulnerable, and helpless to defend themselves. She was indicted
under the Criminal Code of Canada.
Box 8.2 suggests ways for those in clinical practice to avoid legal
problems in the health care environment.
Box 8.2
Strategies for Avoiding Legal Problems.
Workplace Safety
Several Canadian organizations—including the Canadian Centre for
Occupational Health and Safety (CCOHS), the Workers
Compensation Board (WCB, or equivalent), and systems such as
WHMIS—strive to maintain the health of working Canadians by
ensuring that they have safe and healthy workplaces.
Health care providers may have to interact with CCOHS and WCB
in some manner, possibly by helping a patient regain health and
mobility in order to return to his or her current workplace or to
transfer to a new career. The following is a brief overview of these
agencies.
Thinking it Through
You work as an office manager for a family doctor. Genève, a
patient, tells you that her cousin Jason, another patient, is selling
oxycodone that the doctor prescribed for him for pain. Jason does
have a slightly suspicious history of losing his pills or forge ing
them when he goes on vacation and has presented with numerous
excuses to have more oxycodone prescribed. But he has somehow
managed to stay off the radar. Genève tells you not to say anything
to the doctor because she would get into trouble if Jason found out.
She “just thought you should know.” What would you do?
Cannabis (Marijuana)
Legalization of Recreational Cannabis
The use of recreational cannabis was legalized in Canada in 2018 and
is regulated under Bill C-45, federal legislation enabling The
Cannabis Act and amendments to the Controlled Drugs and
Substances Act, the Criminal Code and other Acts. The Act details
the legal framework for the production, distribution, sale, and
possession of cannabis for recreational use, but does not change the
policies and procedures for the use of cannabis for medical
purposes, which has been legally available for over two decades and
is controlled by the Access to Cannabis for Medical Purposes
Regulations (ACMPR) (Wa s, Austin, and Mack, 2017).
Bill C-45 also identifies a range of penalties for anyone breaking
the law(s), particularly related to illegal distribution of cannabis to
younger Canadians. Constitutional powers involving ma ers
affecting cannabis legislation are shared between the Federal
Government and the provinces/territories (Wa s et al., 2017).
Cannabis sales
There is ongoing discussion regarding the distribution of revenue
from the sale of cannabis. Should these products be taxed and how
would this be done? One example is linking taxation to the amount
of THC (the psychotropic component) in the drug. It is widely
recommended that medical marijuana (prescribed pharmaceutical
products derived from cannabis have a Drug Identification Number
[DIN]) should not be subject to taxation.
Thinking it Through
Over the past few years, wait times for diagnostic tests, specialists’
visits, and some types of surgery have become longer.
Eligibility
A person must meet all of these criteria:
Consent
Informed consent, as with any medical procedure that requires the
applicant to be competent, must ensure that a patient is made aware
of, and understands, all the necessary medical details and options
the person may not have tried. This includes pain control and other
palliative care measures, such as counselling and support for mental
and emotional issues, including related anxiety and depression (the
la er must be ruled out as the sole reason behind a decision to apply
for MAID). It is reasonable to assume that many individuals
applying for MAID are experiencing stress, and perhaps are
depressed because of their situation, but of sound mind and thus
clear and certain about their decision. If practitioner is unsure about
the person’s mental status (including depression), he or she can
order a psychiatric consult.
All details of the procedure itself must be understood by the
applicant. The applicant must sign a consent form at the time of the
initial interview when the request is made, and again prior to the
assisted death. There must be a specified time frame (e.g., 10 days)
from the date of signing the request to the day on which MAID is
carried out. This time frame can vary from one jurisdiction to
another. In all jurisdictions, the person can withdraw consent at any
time. The physician/NP must ask the person one more time prior to
the event if the person wishes to withdraw his or her request.
Additional Safeguards
Additional safeguards (other than those discussed earlier) ensure
that MAID is not abused or mishandled. These include stipulating
that the applicant must make the initial request in writing, or have a
competent adult who understands the process, its implications, and
outcomes make the request for them with the applicant present. A
competent adult independent witness must be present when the
request is made. This person must also understand the process and
its implications. This person cannot be involved in the applicant’s
circle of care, or benefit in any way from the death of the applicant.
In addition, a physician/NP must agree that the applicant meets
eligibility criteria applicable in his or her jurisdiction, and have this
assessment confirmed by an independent physician/NP
(Government of Canada, 2018c).
Thinking it Through
One of the criteria set out in Bill C-14 states that the person
requesting MAID is mentally competent and must be able to
consent once again to the procedure at the time of implementation.
This poses a dilemma for people who may become confused during
the time between being approved for MAID and when the actual
procedure is scheduled to occur. What are your thoughts? Do you
think this is reasonable? Do you see a legal, ethical, or moral way
around this stipulation? Are you comfortable with it as is?
The legality of private services in canada
As mentioned, for the most part, a Canadian cannot buy insurance
for, or access private health for medically necessary procedures (e.g.,
cardiovascular or orthopedic surgery).
Those in favour of a strictly purely public health care system may
fear that parallel private health services have the potential to erode
our public health care system and reduce access to health care for
those who must rely solely on the public system.
Consequently, controversy continues over whether there’s a place
for expanded private health care (for medically necessary services
and procedures) beyond complementary and supplementary
services.
All provincial and territorial governments fund certain types of
medical/surgical care—for example, cataract surgery, hernia repairs,
and knee surgery—in private clinics under specified conditions.
Governments also pay for other services, such as diagnostics in
private clinics with which they hold contracts. And Canadians
everywhere can purchase private insurance for nonmedically
necessary health care.
In 2017, it was estimated that there were over 70 private clinics in
Canada with the majority in British Columbia (BC), followed by
Ontario, Quebec, Alberta, and Saskatchewan. These clinics offer
screening procedures, diagnostic imaging, ophthalmology, and
surgical procedures. Some offer overnight accommodation, which
must be approved by the government. Some clinics charge the
patients for services performed within the clinic, referred to as
enhanced services or private options. These include charges for
consultations, assessment reports, accommodation, be er quality
medical devices (e.g., parts used in hip or knee replacement) or
superior cataract lens, and lab tests that may or may not be covered
by the public plan. The amount that clinics charge patients varies
widely. For example, a person might pay an annual fee for what is
called an “executive wellness plan.” This allows prompt access to a
physician (who may be paid at least in part by the clinic and
working both inside and outside of the provincial plan). A physician
in this type of position has two sources of income. For example, a
specialist who has a private practice and bills the province/territory
on a fee-for-service basis, and who also performs procedures within
a private clinic and is paid by the clinic.
Thinking it Through
Dr. Isaac is an orthopedic surgeon who owns a private clinic, Selkirk
Surgical. At the clinic, he along with two other surgeons perform
surgeries for the hip, shoulders, and knees. In addition to owning
the clinic, he also has a busy practice and operates two days a week
in the public system. Nancy, who has been suffering from a knee
problem for several years was referred to Dr. Isaac. She was told she
would have to wait 8 months just for a consultation, and that
potential surgery would be at least another 6 months wait. Nancy is
distraught and asks to be notified if there is a cancellation. The
medical assistant taking her information suggests Nancy may want
to go see the doctor for a consultation at his private clinic. The cost
of the private consultation is $600.00. The surgery at the clinic
would cost $2000.00 and could be performed within a month.
Types of Consent
Express Consent
Express consent can be wri en or oral (which may be directed by
agency policy) and indicates a clear choice on the part of the patient.
Express consent usually requires that the individual be fully
informed as to the benefits, risks, and consequences of any treatment
options.
Written Consent
All major medical interventions require signed, wri en consent as
confirmation that the appropriate process for obtaining consent was
followed and that the patient has agreed to the proposed
intervention. Ideally, the person signing the consent form
understands what the intervention is, including its risks and
benefits. Although wri en consent provides health care providers
with evidence of consent, a signed consent form may be weighed
against any conflicting evidence, and therefore may not provide a
solid defence in the case of legal action.
Most consent forms have to be signed by the patient, dated, and
witnessed. People qualifying as a witness to consent vary among
jurisdictions and health care organizations. For medical procedures,
including minor or major surgery, a physician or registered nurse
will usually witness the consent. The witness should be comfortable
that the patient understands what he or she is signing (e.g., a nurse
ge ing a consent for surgery from a patient and signing as the
witness). If any doubt remains, the appropriate person (e.g., usually
the physician, nurse, or technologist doing the procedure) should
speak to the patient and provide clarification. In some situations
(e.g., in the hospital) reviewing the nature of the procedure is
important, as medical terms can sometimes be confusing or
misleading; the witness, if a health professional, should ensure that
what the patient has been told agrees with the nature of the
procedure he or she is consenting to (Case Example 8.5). Consent
forms may be mailed/emailed to patients beforehand to be reviewed
and signed—in this case it is incumbent upon the patient to seek
further information if required.
Case Example 8.5
Prepared to sign a consent form for a straightforward hysterectomy,
Pia reads through the form given to her by the nurse. The type of
surgery named on the form is a pan-hysterectomy, which Pia may not
understand. If she does not ask for clarification, she will sign
consent for removal of her uterus, fallopian tubes, and ovaries.
Oral Consent
Equally binding as wri en consent, oral consent is given by spoken
word over the phone or in person. At times, someone other than the
patient may be asked to sign consent to surgery; however,
depending on the situation, some facilities ask that two health
providers validate a telephone consent. For example, if a husband
gives telephone consent for a procedure for his wife, assuming she is
unable to give consent, two health care providers must be on the
telephone to validate the husband’s consent—that consent was
given, that he has had all of his questions answered, and that he
fully understands the circumstances under, and for which consent is
being provided. Protocol may vary among facilities and
jurisdictions.
When a health care provider receives oral consent, he or she
should carefully document it in the patient’s chart, describing the
intervention discussed, stating that the patient has acknowledged
understanding of the intervention, and noting that the patient has
agreed to it orally. Wri en consent remains the preferred alternative,
however, for complex treatments.
Implied Consent
Implied consent occurs by virtue of the fact that an individual seeks
the care of a physician or other health care provider. For example,
many people have received an immunization or another treatment
from a family physician without having signed a consent form; the
immunization or treatment has been provided under the umbrella of
implied consent. As previously mentioned, however, more and more
health care providers are requesting wri en consent, even for
immunizations.
By allowing themselves to be admi ed to hospital, patients imply
their consent to certain interventions (e.g., allowing the nurse to give
them a bath or to take their vital signs). This also includes the
sharing of medical information among those caring for the patient,
but not anyone outside their circle of care. However, it is proper and
respectful to ask the patient if they are comfortable with certain
interventions (e.g., “Roger, I am going to begin your exercises now.
Is that okay?”; “Emiko, I would like to change your dressing in
about an hour. Are you okay with that?”). Patients may provide or
deny consent through their actions, such as by nodding (“yes”) or
shaking their head (“no”). A patient’s refusal to treatment should be
documented in detail on his or her medical record, along with any
reasons provided.
Privacy Act
Enacted in July 1983, the Privacy Act requires federal government
departments and agencies to limit the private information they
collect from individuals. The Act also restricts the use and sharing of
any collected information. Additionally, the Privacy Act allows
individuals to access any information federal government
organizations have about them.
Confidentiality
All health care providers must legally and ethically keep all health
information confidential. The concept of confidentiality refers to the
health care provider’s moral and legal obligation to keep a patient’s
health information private. Conversely, the concept of privacy refers
to the patient’s right for his or her health information to remain
confidential and to be released only with his or her consent.
Any health care provider involved directly in a patient’s case—the
circle of care—legally has access to that relevant portion of the
patient’s information. In the hospital se ing, the circle of care may
include the doctors, nurses, social workers, physiotherapists, and
other members of the health care team who are instrumental in the
patient’s care and rehabilitation. Administrative personnel also have
access to a person’s health information and likewise must keep it
confidential. Almost all places of employment—particularly in the
health care sector—require employees to sign a confidentiality
agreement (see Web Resources on Evolve for a link to a sample
agreement) and to adhere to the principles and policies within the
document. Every facility will have policies and procedures for
protecting the patient’s right to confidentiality, from the fact that
they are seeking care, to any and all health information in all forms,
including oral exchanges between or among health care providers.
As a rule, health care providers should never discuss health
information with anyone other than members of the health care team
responsible for the patient’s care. It is unacceptable to mention to a
friend that Sally just had a baby boy or that Pang broke his leg and
has a cast (Box 8.3).
Box 8.3
Confidentiality: An Age-Old Concept.
The concept of confidentiality was outlined in the Hippocratic Oath
2500 years ago as follows:
Whatever, in connection with my professional practice, or not
in connection with it, I see or hear, in the life of men, which
ought not to be spoken of abroad, I will not divulge, as
reckoning that all such should be kept secret. While I continue
to keep this Oath unviolated, may it be granted to me to enjoy
life and the practice of the art, respected by all men, in all times.
But should I trespass and violate this Oath, may the reverse be
my lot.
Source: The Internet Classics Archive. (n.d.) The oath, by Hippocrates. Retrieved
from h p://classics.mit.edu/Hippocrates/hippooath.html.
Security
Health records of any type must be kept in a manner that is both safe
and secure, meaning they should be protected from fire and damage
from environmental disasters such as flooding, among other possible
scenarios. In the case of electronic records, the use of encrypted
software and passwords is essential. All health information must be
stored in such a manner that access is restricted to authorized
persons. Hard copies of electronic information and copies of paper-
based information must be carefully tracked. Anyone who has access
to health information must be bound by confidentiality agreements
(from physicians to administrators to nonregulated health care
providers). Every functioning electronic system should have a
functioning audit trail. Any health care worker who suspects an
unauthorized person of trying to access health information, whether
within a clinic or a hospital unit, should question the person’s
identity and intent. Most health care providers and health facilities
have protocols for both storing and allowing access to health
information they are responsible for.
LEARNING OUTCOMES
KEY TERMS
Active euthanasia
Advance directive
Autonomy
Beneficence
Compassionate interference
Continuity of care
Deontological theory
Divine command ethics
Double effect
Duties
Ethical principles
Ethical theory
Ethics
Fidelity
Fiduciary relationship
Involuntary euthanasia
Medical Assistance in Dying (MAID)
Morality
Morals
Nonmaleficence
Passive euthanasia
Paternalism
Rights in health care
Role fidelity
Self-determination
Teleological theory
Values
Values history form
Virtue ethics
Voluntary euthanasia
Values
Values, beliefs important to an individual, guide a person’s conduct
and the decisions he or she makes. People can have personal values,
social values, and workplace or professional values. A person who
greatly values friendship may consider their relationship with a
particular person more important than, for example, a material
object. And although a person may value friendship in general, one
friend may be more valued than another. Context may also influence
values, and therefore behaviour (Case Example 9.1).
Sense of Duty
Duties often arise from others’ claims. If a patient depends on you
(i.e., has a claim on you) for your professional services, you have a
duty, or obligation to deliver these services. As a member of the
health care profession, you also have a duty to behave in an ethical,
moral, and competent manner. Alternatively, duties may be self-
imposed. For example, a person who values honesty will make it
their duty to be truthful.
Health care providers, by the very nature of the field they work in,
have a moral and ethical duty to care for their patients in a
competent manner, in addition to a legal obligation, called the “duty
of care.” As discussed in Chapter 8, the legal component of this duty
requires health care providers to provide patients with a reasonable
standard of care in accordance with their profession’s standards of
practice. In terms of a moral obligation, health care providers are
expected to provide care even in situations that may threaten their
own lives or health; however, they may not be legally bound to do
so.
Thinking it Through
The worst Ebola epidemic began in West Africa in 2014. The disease
is highly infectious with a high mortality rate among those infected.
The Canadian Red Cross sent health professionals including
physicians, nurses, and other disaster response personnel. Sasha, a
nurse, contracted the virus and was transferred back to your
hospital in Canada. He has been placed in isolation. You have been
asked to provide his treatment despite considerable risk of
contracting the infection yourself.
Teleological Theory
Teleological theory, also referred to as consequence-based theory,
defines an action as right or wrong depending on the results it
produces. Theoretically, the “right” action brings about the most
benefit for the most people. Consider Case Example 9.3, a real-life
situation.
Deontological Theory
Deontology developed from the word duty. In the case of
deontological theory, a moral and honest action is taken, regardless
of the outcome. If in Case Example 9.3 the team had used a
deontological approach and did the “right” thing, they would have
removed the sponge, or they would have told the family what had
happened, explained the risks, and allowed them to make the
decision.
Virtue Ethics
Virtue ethics looks at the ethical character of the person making the
decision, rather than at his or her reasoning. This theory operates
under the belief that a person of moral character will act wisely,
fairly, and honestly and will uphold the principles of justice.
Therefore virtue ethics, unlike teleological and deontological
theories, do not provide guidelines for decision making.
In Case Example 9.3, several people were present for the
postsurgery discovery. Person A may have decided that it would be
best not to divulge the incident about the sponge, whereas Person B
may have decided the incident must be exposed. Each person would
make an individual decision based on their own set of values and
morals. However, a common decision must often be reached. When
people disagree about the course of action to take, sometimes the
majority will rule; other times, one person may have the authority to
make a call. However, each person should still feel comfortable with
their own actions, because each person might have to take
responsibility for such actions. In the case example, individuals
following the principles of virtue ethics may believe that the surgeon
has high moral principles, and therefore will refrain from
questioning the surgeon’s decision. In addition, they may believe
that loyalty to the surgeon is a virtue. Then again, the act is both
illegal and contrary to hospital policy, so these individuals may take
a personal risk by complying with the decision not to report the
incident. Ultimately, each person must weigh the situation,
determine to whom they owe the greater loyalty, and decide
according to their own conscience.
Divine Command
The most rigid ethical theory, divine command ethics, follows
philosophies and rules set out by a higher power. For example,
Christians must live by the Bible’s Ten Commandments, a list of
religious-based moral laws. Muslims follow the rules outlined in the
Koran, such as maintaining a just society and engaging in
“appropriate” human relationships. In Case Example 9.3, followers
of divine command ethics would without question decide that the
incident should be reported because honesty makes up a significant
part of the divine command theory.
Thinking it Through
Dr. Kowalski decides not to reveal to Jake (an older patient with no
relatives or emotional support system) the nature of his illness—
amyotrophic lateral sclerosis (ALS), which causes progressive
paralysis eventually leading to the inability to swallow or breathe.
The physician believes that she is sparing Jake unnecessary grief, at
least for the short term.
Respect
Another key ethical principle is respect. All patients have the right to
be treated with respect by those who care for them. Health care
providers and their colleagues also have this right. Respecting others
involves honouring their right to autonomy (see later), being
truthful, not withholding information, and honouring their
decisions, whether stemming from personal, religious, cultural, or
societal influences.
Autonomy
Autonomy comes from the Greek autos, meaning self, and nomos,
meaning governance. The ethical principle of autonomy underscores
a person’s right to self-determination. Autonomy recognizes the
right of a mentally competent individual, given all of the relevant
facts, to make independent decisions without coercion (i.e., pressure
or force). Health care providers may try to influence a patient’s
decisions, often unintentionally, thinking they know what is best.
However, patients have the right to choose their own course of
treatment or to refuse treatment altogether.
Truthfulness
Truthfulness (also referred to as veracity), a valued principle that
patients should expect of a health care provider, contributes to
building a bond of trust vital to any patient–health care provider
relationship. Without this bond an effective relationship is
impossible. Withholding the truth is rarely justifiable, shows
disrespect, and works against a person’s autonomy and rights.
A special relationship, called a fiduciary relationship, exists
between health care providers and their patients. To some degree,
the health care provider retains a position of power over the patient,
considering the patient’s dependence on the health care provider for
his or her care. In such a relationship, patients should expect the
health care provider to care about them as well as for them, and to
be honest and trustworthy.
Thinking it Through
Mekhi has a serious illness, but a treatment option that will
potentially cure his illness is available. His doctor tells him about
the treatment, but fearing Mekhi may decide to refuse the treatment,
he does not inform him of the serious side effects that he will likely
experience.
Fidelity
The principle of fidelity—faithfulness or loyalty—requires health
care providers to adhere to their professional codes of ethics and the
principles that define their roles and scopes of practice, and also to
fulfill their responsibilities to patients by practising their skills
competently. The term fidelity comes from a Latin root word
meaning to be faithful. Fidelity therefore requires faithfulness and
loyalty to patients, colleagues, and employers (Case Example 9.4).
Health care providers are also expected to uphold the rules and
policies of the organization (or person) for which they work. In the
workplace, role fidelity becomes an important ethical principle for
health care providers as they work to honour patients’ wishes and to
earn the trust essential to the professional–patient relationship.
Case Example 9.4
Cecelia, who manages a number of urgent care clinics, is on a bus
and overhears a conversation between two young women in the seat
in front of her. “That clinic is the worst,” says one. “They expect me
to do everything they ask, and they want it done, like, yesterday.”
“Yeah,” responds the other, “I know what you mean. I bet you
hate working there. It sounds like that manager is a real dragon. I’d
never go to that clinic—unless I was dying and there was nowhere
else to go!”
Cecelia recognizes one of the women as an employee. Needless to
say, the clinic staff will be subject to a discussion about loyalty the
next day.
Justice
The principle of justice applies, in one way or another, to most
ethical situations. In health care, for example, it raises questions such
as the following: Do all patients get the appropriate (i.e., just)
treatment? Are health care resources fairly distributed? Are the
patient’s rights honoured? The three main types of justice are
distributive, compensatory, and procedural. Distributive justice deals
with the proper and equitable distribution of health care resources.
Distribution may not be equal because it is prioritized and based on
need. Compensatory justice relates to the paying of compensation for
wrongs done (e.g., if a person can prove that they developed cancer
from working with asbestos, the company may have to compensate
that person financially for pain and suffering and cover pertinent
medical expenses). Procedural justice points to acting in a fair and
impartial manner (e.g., seeing patients on a first come, first served
basis; not giving preferential treatment to a friend).
The Canada Health Act entitles all Canadians to equal access to
prepaid health care and physician and hospital services. However,
with resources stretched to their limits and long waiting lists for
many services, equal access is compromised, along with other
principles of the Act. Health care providers must do what they can
to provide the best services to their patients.
Health care providers must practise within the boundaries of the
law and report any actions that break the law or compromise the
health or safety of a patient. Most organizations set up a process for
reporting unethical or illegal behaviour. It is important to learn this
process and to follow it, no ma er whom—an employer, a peer, or a
superior—one finds acting unethically. By simply having knowledge
of an illegal or immoral act and not reporting it, a person may be
considered guilty in the ma er. Consequences can range from a
tarnished professional and personal reputation to legal action and
patient harm. In Case Example 9.3, Nima may disagree with the
decision not to report the missing sponge, but by not reporting it she
could share the guilt in any ensuing legal action.
Justice in health care also considers the allocation of health care
resources, which raises questions about whether health care services
are spread evenly across Canada. The allocation of resources is
discussed in more detail later in this chapter.
Patients’ Rights in Health Care
Numerous moral controversies surround rights in health care, such
as the right to die, the right to self-determination, the rights of a
fetus, the rights of women to abortion, smokers’ rights, and the
rights of an individual to health care. These are addressed in one
way or another under the Canada Health Act and the Canadian
Charter of Rights and Freedoms (see Chapters 1, 3, and 8).
Technological advances have raised questions about an individual’s
right to certain health care services and procedures, including, for
example, in vitro fertilization (IVF). Depending on the jurisdiction,
the cut-off age in Canada for IVF ranges from 45 to 50 years old. But
is it fair to place such limits on who may receive the procedure?
Should older women be given a right to it? Should the number of
embryos implanted be limited? If such limits are put in place, and a
woman travels out of the country to have multiple embryos
implanted, should her provincial or territorial plan be responsible
for her medical costs? In vitro fertilization in older women and the
implantation of multiple embryos into a woman’s uterus, regardless
of her age, both present significant risks to mother and baby (or
babies). When complications arise, they cost the health care system
millions of dollars.
Box 9.1
A Modern Version of the Hippocratic Oath.
I swear to fulfill, to the best of my ability and judgement, this
covenant:
Source: Nova Online. (n.d.). The Hippocratic Oath: Modern version. Retrieved
from h p://www.pbs.org/wgbh/nova/doctors/oath_modern.html.
Thinking it Through
Patients frequently ask health care providers for advice based on
their specific professional knowledge and expertise. For example,
Jennifer, an asthmatic, may ask a respiratory therapist whether she
should use her inhalers as often as prescribed by her medical
specialist (e.g., an internist)
Truthfulness
All patients have a right to the truth, and health care providers, as
discussed earlier, have a duty to provide it. Expecting that others
will be truthful and honest is central to trust, even in our daily lives.
The patient-focused (not physician-focused) approach to
treatment requires physicians to keep the patient fully and truthfully
informed. Denying information to patients or deceiving them causes
more harm than good in most situations. Being truthful supports key
ethical principles, those acting with beneficence or doing only what
is proper and right, and refraining from doing harm, or
nonmaleficence and autonomy (the right to self-determination). It is
also necessary to tell the truth to uphold these principles and to
adhere to the concept of duty, which is central to health care ethics.
See Case Example 9.5. Does postponing telling a patient the truth
justify withholding information?
Thinking it Through
In the workplace se ing, you will meet a wide range of people,
some of whom you are drawn to and feel a natural desire to want to
develop a friendship with.
With colleagues
Inevitably, you will develop friendships in the workplace. Unless
these friendships interfere with how you do your job, doing so is not
considered unethical. However, you must remain impartial and not
choose favourites among the staff. Developing alliances by forming
cliques at the expense of others is both unprofessional and
destructive. Tight-knit groups in the workplace make it difficult for
new staff members to integrate and feel welcome. Starting a new job
is difficult enough. A warm and inviting environment goes a long
way toward helping new employees fit in and begin to function
competently as a member of the health care team.
Personal business has no role in the workplace, either. Discussing
last night’s party, tomorrow’s trip, or someone’s recent breakup
remains inappropriate in any work environment.
In the hospital setting
Health care providers employed in a hospital se ing are expected to
carry out their duties in a professional, legal, and ethical manner. All
health care facilities have procedures, policies, and guidelines
governing ethical conduct. Employers also expect health care
providers to uphold the ethical codes of their individual professions.
Although members of the health care team should support each
other, overstepping certain boundaries can breach ethical conduct
(e.g., moving a colleague’s family member up a wait list).
Health care providers also have an obligation to report a fellow
health care provider’s misconduct or incompetence, whether
regarding their job performance or a violation of the principles of
confidentiality. Most health care environments develop procedures
outlining what to report and whom to report it to. Ethical issues
unresolved at a lower level, in most facilities, will be reported to an
ethics commi ee.
Vulnerability
The patient occupies a vulnerable position within the patient–health
care provider relationship. As a result of this vulnerability, the
patient may exhibit sick role behaviour (see Chapter 7) and feel
dependent.
Accepting gifts
Patients often give gifts to health care providers who have cared for
them, usually as an expression of gratitude. Li le literature is
available about the ethics of accepting gifts. A box of chocolates for
the nursing station when a patient leaves the hospital, some flowers
sent to the office, or a card with a small ornament are examples of
acceptable gifts. Accepting anything more is inappropriate and may
place the health care provider in a difficult position because the
patient may expect favouritism, such as access to special treatment
or an appointment whenever he or she wants it. Some health care
providers make it a policy not to accept anything—ever. If an
employer or regulatory college has guidelines about accepting gifts,
these must be followed.
Seasonal gifts may be an exception. During the holidays, patients
often give health care providers and their office staff gifts, such as
home baking, wine, or other tokens of appreciation—usually with no
strings a ached. Some people get a true sense of satisfaction from
the opportunity to express gratitude. Common sense and familiarity
with the patient are the best guidelines when accepting seasonal
gifts if the workplace or regulatory college does not address the
issue.
Euthanasia
Various categories of euthanasia exist. Voluntary euthanasia occurs
when a person causes the death of another with the dying person’s
consent—often in the form of a living will or advance directive
(involuntary euthanasia occurs when a person causes the death of a
dying person without the la er’s consent, usually associated with
murder). Active euthanasia refers to the taking of deliberate steps to
end another’s life (e.g., with a lethal injection such as in the case of
Elizabeth We laufer using insulin to kill her patients, see Chapter 4);
passive euthanasia refers to the process of allowing a person to die
by removing life support or other life-sustaining treatment. This can
occur at the patient’s request expressed close to the time of death, by
means of a living will, or in some cases a decision made by the
physician or a proxy decision maker. In the case of medical
assistance in dying (MAID), the doctor provides the patient with the
means to end his or her own life; the patient, however, carries out
the act. This of course is now legal in Canada.
With the exception of passive euthanasia, and medical-assistance
in dying where legal, the act of ending or assisting to end a person’s
life is illegal in most countries. Euthanasia including MAID remains
a highly controversial concept, and depending on the situation, has
both legal and ethical implications. Any act that takes someone’s life
act conflicts with the moral values of most societies, which respect
the sanctity of life and the duty of the health care provider to save or
preserve life. On the other hand, allowing physician assisted aid in
dying respects the autonomy of the person who wishes to die.
Thinking it Through
Debate over the ethics in the Latimer case and the severity of the
sentence Mr. Latimer received continues to this day. At Mr.
Latimer’s second trial, ordered because of jury interference in the
first trial, the jury upheld the charge of second-degree murder, but
recommended Mr. Latimer be eligible for parole after 1 year. In this
trial, Justice Ted Noble tried to distinguish between murder and
mercy killing. He called Tracy Latimer’s murder a “rare act of
homicide that was commi ed for caring and altruistic reasons. That
is why for want of a be er term, this is called compassionate
homicide” (CBC News, 2010). Did Robert Latimer ever present a
danger to society? Most would say no. However, in 1994 the
Saskatchewan Court of Appeal overturned Judge Noble’s ruling,
imposing the mandatory minimum sentence: 25 years, with no
parole for ten years. Latimer’s first bid for parole in 2007 was denied
because he maintained his belief that he killed Tracy for her benefit
and would not express remorse. Groups championing the rights of
disabled persons argued that showing leniency would endanger
disabled persons and rate them as second-class citizens. Canadians
with disabilities continue to campaign for protection of what they
deem a fundamental human right—the right to life (CBC News,
2010).
Today, after 25 years, Robert Latimer at home on his family farm
(on parole) still has no regrets. He feels he did the right thing. He
holds a veiled hope that the current Federal Government will
pardon him.
Source: CBC News. (2010, December 6). “Compassionate homicide”: The law
and Robert Latimer. CBC News. Retrieved from
h p://www.cbc.ca/news/canada/compassionate-homicide-the-law-and-robert-
latimer-1.972561.
Autonomy
Proponents of medical aid in dying claim that the legislation
supports the rights of the individual to autonomy, self-
determination, and the right to choose their destiny when faced with
an illness or disability causing intractable, intolerable pain, and
suffering. The principle of self-determination is often central in
medical decisions. The key is that the person is mentally competent
to make their own decision.
Values
When weighing the ethical rightness or wrongness of seeking
medical aid in dying, a person’s values must be considered. For
example, most people value their personal dignity. Personal dignity
may include a person’s self-worth and sense of pride—for example,
in being able to look after themselves in the final stages of an illness.
He or she may fear a loss of dignity if they cannot render self-care,
depend on others for meeting such needs as feeding, and
elimination, entities the person associates with quality of life (or lack
there-of). Loss of dignity is almost always associated with cognitive
impairment, and feared as an illness progresses.
Trust
Primary care providers almost always have a mandate to preserve
life, to do no harm, and to bring about good (the principles
beneficence and nonmaleficence). The concept of deliberately
bringing about or contributing to a person’s death violates almost
every principle of duty ethics that health care professionals pledge to
uphold. Does this weaken trust between a patient and health
practitioners who participate in MAID?
Medical assistance in dying and whether it is right or wrong will
always depend on an individual’s own ethical and moral beliefs and
values. The process will continue to pose more questions than
answers. In addition, the policies and procedures including
eligibility still require adjustment. What does foreseeable death
mean? It is subjective and it is up to the clinician to make that
decision. Some judges have already ruled (in response to specific
legal challenges) that there is no time limit on when death might
occur, and have deemed a person eligible for MAID even when their
medical state is not terminal. Are there enough safeguards in place
to prevent misuse of the process? Will it become “ordinary” so that
those assessing eligibility become complacent, creating a slippery
slope that could lead to misuse of the process? Should individuals
diagnosed with Alzheimer disease and other forms of dementia be
allowed to make arrangements for MAID while they are still
mentally competent? Should those with mental illness be eligible?
Should minors be allowed to make such decisions? Is it reasonable to
allow someone to have assistance in ending their life to end lifelong
suffering, even when death is not imminent?
Thinking it Through
Currently hospitalized Pierre suffers a cardiac arrest. His nurse,
Nayla, is in his room at the time and knows that he has a wri en
and signed DNR order because he was constantly reminding the
staff of it. However, because of Nayla’s religious beliefs, she feels
that saving a person’s life takes precedence over everything else.
Not resuscitating Pierre is a difficult choice for her to make, but
resuscitating him would violate the patient’s personal request and
thus his right to autonomy.
Palliative Care
Palliative care, an increasingly important component of medical care
in Canada, addresses the physical and emotional needs of those who
are dying. Individuals opposed to any kind of interference with the
natural course of death believe that palliative care can facilitate a
peaceful and painless natural death. Whether delivered in a hospital,
in a hospice, or at home, palliative care can aid any person who is in
the la er stages of a terminal illness, or cannot otherwise cope with
their disease without specialized support. Teams of experts work
with patients and their families to manage physical discomfort and
psychological distress and to meet spiritual needs.
Care in a Hospice
Hospice care is a form of palliative care offered in a facility
especially designed and staffed to deliver patient and family-centred
care for patients who are in the la er stages of a terminal illness. The
main goals are patient comfort, relief of pain and other symptoms,
and support for the person’s family and loved ones. A medical and
holistic approach to care and support are integrated with spiritual,
mental, and emotional needs of both the patients and their families.
The nurses, physicians, and other health practitioners are experts in
pain control and related interventions. It is often argued that proper
palliative support for the patient is a be er option than physician
assisted dying, and that properly managed, a patient can die with
dignity without pain or undue stress. There are also those that argue
that even the best palliative care cannot always meet the needs of the
patient. and for those who are ethically, spiritually, and morally
comfortable with MAID, it is their right to pursue that course of
action.
Allocation of resources
The term allocation of resources refers to who gets what, when, and for
what reason. Rising health care costs, expensive technologies, and
limited access to many services have made the allocation of
resources an increasing concern in the health care industry. And
limited resources mean that “Who gets what?” becomes a huge
ethical problem. A brief discussion of select limited resources
follows, with the intent of promoting thought and discussion.
Organ Transplantation
The advancements that led to the ability to transplant organs, a
scarce resource, have introduced several ethical issues. Consider
Case Example 9.8.
Thinking it Through
Thousands of Canadians suffer from relatively rare conditions that
are incurable. but that can be treated with some success. These
treatments, however, are often extremely expensive—sometimes
drugs are not covered by the public plan, and sometimes treatments
do not fall within the definition of “medically necessary.”
Thinking it Through
Communities in Canada’s far North are geographically isolated,
generally with small population centres spread over this immense
area, often with living conditions that are harsh in comparison to
life in what northerners call "the South." Most communities have
health centres staffed by nurse practitioners or registered nurses.
Doctors visit some of the communities on a rotation basis. There is
limited availability to diagnostic equipment, treatment, and
surgeries. Even giving birth requires evacuation of the mother to a
larger centre weeks before the delivery date. Having to leave their
community for medical care, in addition to coping with illness
outside of one's community without the support of family and
loved ones, brings added stress.
Premature Deliveries
There is current disagreement as to when extreme measures to save
a premature baby should be abandoned, many recommending that a
baby born prior to 22 weeks gestation should not be aggressively
treated. This is very controversial as some babies born at 22 weeks
have survived. Questions regarding the accuracy of gestational age
also come into play. Others include the rights of the baby versus the
chance of surviving with a good quality of life. Who decides? What
is a good quality of life to one person may be different from that of
another. Should cost be considered, weighted against the odds of
survival?
Genetic Testing
An increasing number of Canadians are having genetic testing—the
examination of one’s deoxyribonucleic acid (DNA)—done through a
number of online organizations such as www.23andMe.com and
www.Ancestry.com providing direct-to-consumer results. Through
genetic testing people can learn whether they carry any genes that
put them at a higher risk for disease, such as certain types of cancer
(e.g., breast), Alzheimer disease, and Huntington disease. Similarly,
carrier testing determines whether the potential exists to pass on a
genetic disease (e.g., sickle cell anemia and cystic fibrosis) to
offspring. A couple who undergo such tests and have positive
results must then weigh the severity of the potential disease and the
chances of its occurrence when deciding whether to bear children.
Prenatal diagnostic screening can determine a fetus’s risk for
certain genetic disorders, aid in earlier diagnosis of fetal
abnormalities, and provide prospective parents with important
information for making informed decisions about a pregnancy.
Genetic testing raises a number of moral and ethical questions,
however. For instance, if an insurance company obtained records
showing that a prospective patient carried a gene that put them at
risk for developing cancer, would that person be considered
uninsurable? Would an employer with access to similar information
decide against hiring that person? Some protection is provided for
individuals in possession of genetic testing results revealing health
concerns that could impact their purchase of insurance policies. Bill
S-201, an Act to Prohibit and Prevent Genetic Discrimination, was
passed in Canada in early 2017 (Government of Canada, 2017).
Under the Act insurance companies are barred from asking clients to
provide them with the results of genetic testing they may have had
done when applying for life insurance under the amount of $250K,
or for health insurance. The Act amends the Canada Labour Code to
prohibit employers from requiring that employees have genetic
testing done, or from revealing test results already in the employee’s
possession. The Act also amends the Human Rights Code to prohibit
any type of discrimination of a person based on genetic
characteristics (e.g., someone with obvious characteristics of Down
syndrome). There are still concerns if damaging genetic information
y g gg
somehow fell into the wrong hands, and it can still be requested by
insurance companies for more expensive life or health insurance
policies. Do you think the fact that Canada has a universal health
care system lessens the potential harm of being required to reveal
genetic test results when purchasing private health insurance?
What the individual does with the information obtained raises
further issues. For example, a woman who learns she has the breast
cancer gene might elect to have her breasts and ovaries removed.
The famous American actress Angelina Jolie had a prophylactic
double mastectomy based on a family history and on a positive
BRCA genetic test. Two years after this surgery, Jolie had her ovaries
and fallopian tubes removed prophylactically.
Thinking it Through
The presence of the BRCA1 or BRCA2 genes can predispose a
woman to cancer of the pancreas and the uterus as well. Not all
women elect to have any of these surgeries, even if they have either
or both of these genes. Instead, some will opt for close monitoring
for disease detection.
LEARNING OUTCOMES
10.1 Discuss the state of mental health and addiction and the
related services in Canada.
10.2 Summarize the challenges in managing health care for
Canada’s aging population.
10.3 Explain the problems facing home care services in Canada.
10.4 Describe current issues related to pharmacare and the
legalization of marijuana in Canada.
10.5 Outline the major health care issues and related concerns
facing Indigenous Peoples in Canada.
10.6 Explain the impact of electronic health records and
information technology in health care.
10.7 Discuss future initiatives for primary health care.
10.8 Summarize the advantages and risks of using social media
in health care.
KEY TERMS
Food insecurity
Forensic psychiatric hospitals
Reserve
Community-Based Services
Community-based mental health care is provided in a variety of
ways. Many jurisdictions offer a centralized point of contact to help
people navigate the mental health care system and to provide them
with direction about their legal rights, when required (e.g., Alberta’s
Access Mental Health initiative).
In every province and territory, health organizations provide care
and public education. For example, the Canadian Mental Health
Association and its nationwide branches deliver services and
support to those with mental health and addiction challenges. This
organization depends heavily on a dedicated team of volunteers to
deliver and maintain its community programs. Other organizations
such as the United Way fund some uninsured services for those
unable to pay, although many services remain accessible only to
people who can afford them.
Mental Health Practitioners
Primary care physicians, psychiatrists, psychologists, nurses, social
workers and counsellors (many of whom are in private practice) are
core members of the mental health primary care team.
Family Physicians
Just under 90% of Canada’s family physicians have some component
of their practice devoted to caring for patients with mental illness,
ranging from depression and anxiety to more serious problems.
Family physicians will refer individuals for specialized mental
health services when they feel the patient needs more support and
direction than they can provide. In addition, many prefer not to
become involved in counselling because it is time consuming
(usually a minimum of a half hour per session per patient), reducing
their availability to see other patients. In a half hour a family
physician could otherwise see three to four patients. Referring
patients to mental health and counselling experts poses challenges,
including a lack of psychiatrists (whose services are covered by
public plans), and the cost of seeing a psychologist or counsellor,
whose services must be paid for privately or through private
insurance. Some primary care organizations will offer limited paid
access to a psychologist (e.g., four visits in a year). Most insurance
companies will pay for a designated number of visits to a
psychologist (with a PhD), but not for someone with fewer
credentials (e.g., a master’s degree). This limits access as well.
Thinking it Through
Many Canadians are reluctant to admit to being diagnosed with
mental illness or that they have a substance addiction. A person
with suicidal thoughts/ideation, despite initiatives such as the Bell
Let’s Talk campaign, may be reluctant to approach someone for
support fearing they will be judged and that people will think less
of them.
Drug Misuse
The misuse of any drug is problematic—opioid (e.g., fentanyl,
morphine) and opioid analogues (synthetic reproductions) are
currently of particular concern. Every province and territory in
Canada has been affected by the national opioid crisis. There were
an estimated 2946 deaths related to opioid use in 2016, and an
estimated 2923 deaths from January to September 2017; over 90%
were accidental. Only one quarter of these deaths were among
females, and those in their thirties accounted for the largest age
group. Most deaths involved fentanyl or fentanyl analogues, and in
2017 occurred mainly in British Columbia, followed by Ontario. The
fewest deaths were in the territories and Prince Edward Island
(Government of Canada, 2018a).
Reducing Homelessness
Strategies to reduce homelessness vary with provinces and
territories, as well as within communities, and are determined by
available resources, demographics, and varying needs of the
homeless in each community. Resources available may or may not
include government funding, funding, fundraising events, planners
and policy makers, service providers, medical and mental health
authorities, community groups and volunteers.
Housing First is a framework widely used across Canada for
developing housing programs for mentally ill homeless people.
Housing First is a product of a Federal Government sponsored 5-
year research project called At Home/Chez Soi. It is an information-
or evidence-based (meaning based on evidence gathered by
research), best-practices platform to reduce homelessness across the
country. One of the key elements within the Housing First
framework is finding permanent homes for homeless people, who
are suffering from mental illness and addiction, without
preconditions or eligibility criteria—for example, the individuals do
not have to maintain sobriety or a end treatment sessions before
being considered for permanent housing.
Providing homeless people with housing through programs like
Housing First dramatically reduces visits to the emergency
department and improves the overall health of homeless individuals.
Because individuals have a permanent address, it is easier for them
to arrange and keep appointments with health providers, thereby
improving continuity of care. Seven cities in Alberta reported that
because of the program, overall hospital stays by homeless people
(days spent in hospital) were reduced by 64%, and visits to the
emergency department were reduced by 60% (7 Cities, 2018). In
Medicine Hat, Alberta, the Housing First initiative, in conjunction
with other community agencies, has all but eliminated homelessness
in the city. The initiative aims to have every homeless person
connected with a support worker, on average within 3 days, and
ideally be moved into permanent housing within 10 days
(Lawrynuik, 2017).
A first-ever National Housing Strategy for Canadians was
announced in the fall of 2017. Building on past frameworks, the
Federal Government pledged to invest $40 billion into housing
programs for vulnerable populations over a 10-year time frame. Of
this, $2.2 billion was set aside for homelessness, adding to a
previously pledged $11.8 million. This national housing strategy is
projected to double the annual budget targeted for homelessness by
2021–2022 when compared to the budgeted amount distributed in
2015–2016. Through Reaching Home (discussed later), increased
funding will be earmarked to reduce homelessness among the
Indigenous population in Canada, in consultation with Indigenous
communities, providing culturally sensitive recourses and support
to meet the unique needs of vulnerable individuals within that
population base.
Members of the commi ee who made recommendations for
reducing homelessness were from diverse backgrounds, including
individuals with actual experience (i.e., who have experienced
homelessness), ensuring that strategies and recommendations
embraced demographic and cultural needs. It is important to note
that the former and new Strategies have considered jurisdictional
barriers (both historic and current) identified by the Truth and
Reconciliation Commission and acknowledged that implemented
practices must be consistent with the Commission’s Calls to Action.
Under the new national housing program, the previously
mentioned Homeless Partnering Strategy was restructured and
renamed Reaching Home: Canada’s Homeless Strategy (effective
2019). The new goal of Reaching Home is to reduce homelessness in
Canada by 50% within a 10-year time frame (by 2028). This strategy
provides direct funding for municipalities and service providers at
the local level. Although there are some guidelines, the Federal
Government does not specifically dictate how funds are to be used in
each community. Some funding does target Housing First programs
as well as those organizations that provide emergency shelter,
support, and services when housing is unavailable. Housing First
programs are encouraged to adapt their programs to respond to the
unique needs of youth, Indigenous Peoples, women seeking refuge
from violence, and veterans. Under the restructured framework,
communities not already receiving support can apply for funding.
The Strategy will provide ongoing support in terms of information,
advice, and the tools they need to structure and deliver system-
based plans to reduce homelessness in a coordinated manner,
utilizing services and resources within their communities. Despite
the best efforts in any community there will always be homelessness.
Why? Some of the reasons include the high cost of housing in some
cities; unavailability of housing and rental units; stigma (i.e., people
not wanting homeless persons sheltered in their neighborhood); lack
of funding; lack of coordinated, effective strategies; and an increased
incidence of mental illness and addictions, with inadequate mental
q
health services. There will always be individuals who require
emergency shelters (many of whom won’t find a bed due to
shortages in hostels and shelters) forcing an individual to remain
outside. During the cold Canadian winters, homeless people are
particularly vulnerable. Cities across Canada scramble to provide
accommodation, sometimes opening facilities as temporary
sanctuaries. Alternatively, outreach workers canvas known locations
providing food, warm drinks, blankets, and sleeping bags
(Government of Canada, 2018c).
There are numerous organizations across Canada that provide
temporary and emergency shelter for homeless people. These
include the Salvation Army (operating in over 4000 communities
across Canada), Out of the Cold (a network of churches and other
religious organizations rotating available facilities), the Sco Mission
in Toronto (providing family accommodation), Young Parents No
Fixed Address, Toronto (focusing on pregnant women and those
with children, and counselling services to young parents), Inn from
the Cold, Calgary (which opened Calgary’s first emergency shelter),
Hope Mission in Edmonton, (also operates a 24-7 rescue van
supplying blankets, lunches, and supplies needed by homeless
individuals), Bissell Centre in Edmonton (providing shelter and
warm meals), the Lighthouse in Saskatoon (offering shelter and
affordable housing). In 2017 Vancouver offered over 300 spaces for
homeless individuals, with funding from the province and the city.
Ending homelessness, if indeed it can ever be ended, is
complicated, and complex; meeting the needs of homeless
individuals with mental illness and addictions is an added challenge
and will require continuous support, innovative strategies, and a
dedicated workforce, including health professionals and volunteers
(Government of Canada, 2018c).
Thinking it Through
Pierre was exhibiting depressive behaviours at work. At times he
was argumentative and defensive. His work productivity slipped,
and he was often absent. After several warnings to “improve,” he
was terminated. Pierre filed a human rights complaint. His
employer was found to have wrongly terminated him and without
due process. The employer had to rehire Pierre, make
accommodation for his depression while Pierre was under
treatment, and reimburse him for lost wages.
1. Why do you think Pierre did not tell his employer about the
depressive episode?
2. What steps should the employer have taken other than
cautioning him to improve?
3. What can employers do to make the workplace less stressful
and to deal with employees experiencing a mental health
problem?
The Future of Mental Health Care
Changing Directions, Changing Lives is the first national strategy for
mental health. Released in 2012, the strategy primarily aims to
improve care for people diagnosed with mental illness across the
country and provide them and their families with the necessary
resources and support. The strategy acknowledges that even the best
and most coordinated treatments and services will fall short of
reducing the impact of mental illness in Canada, which remains in
crisis mode. As with physical health, the promotion of mental health
and prevention of mental illness are fundamental.
Despite the system’s problems, most experts believe the move
away from institutionalized care was the right one. Current thinking
still supports the concept of integrating mental health services into
existing primary care systems and improving interdisciplinary
collaboration on the part of all health care providers.
E-Mental Health
For many Canadians, mobile devices are a part of daily life, used for
business, educational purposes, accessing the news, and staying in
touch with friends and acquaintances. Platforms such as Facebook
and Twi er provide the baseline for social connectivity. Digital
technology is very much a part of health care with the widespread
use of electronic health records and electronic medical records,
sharing laboratory and diagnostic test results, and monitoring
patients’ conditions (e.g., diabetes, hypertension) remotely. E-mental
health technology is relatively new. However, individuals can
already connect to a variety of mental health services, thereby
improving access to health professionals, treatment, and support.
Other advantages of e-mental health include shorter waiting times
and improved access to services in the patient’s language. There are
numerous apps on mobile devices to assist individuals in accessing
web-based support, and self-help therapies, which have proven
effective in managing such disorders as depression, anxiety, and
pos raumatic stress syndrome. Mobile device apps can provide
mood-tracking options and social media support forums, giving
individuals an improved sense of control over their mental health
and treatment. E-mental health options are also valuable tools in
assisting individuals maintain balance and work to prevent mental
health issues. There are numerous online solutions, such as
mindfulness exercises to reduce anxiety, which can be accessed day
or night. Online resources provide a variety of services as described
in the following two cases.
Consider Leslie who is a somewhat anxious person prone to
anxiety a acks. She wakes up feeling overly anxious at 3 o’clock in
the morning; no therapist is available. She accesses an app on her
phone, which guides her through breathing and concentration
exercises that quiet her mind so that she returns to sleep, thereby
avoiding a full-blown anxiety a ack.
Louise, a 16-year-old Indigenous girl, had been consuming alcohol
for a couple of years, sometimes with her parents, mostly with peers,
and mostly on weekends. She found herself drinking more during
the week, especially when she felt depressed about feeling isolated.
Her brother killed himself a year earlier and talking about “ending it
all” was not unusual conversation among her peers. She went to the
local health centre for advice. Counsellors were in short supply,
rotating into the community every couple of weeks. The nurse spent
time with Louise in addition to helping her download an app that
put her in touch with a peer support group of individuals with
drinking problems. Louise felt at ease with the support group.
Although anonymous, she made online friends from across Canada,
some from three larger cities (Toronto, Winnipeg, and Vancouver),
others from rural communities. She found out she was not alone
with respect to her drinking and her thoughts of suicide, and that
geography was not a unique factor contributing to her situation.
Someone from the group told Louise about an online Indigenous
resource that provided online counselling sessions and traditional
coping sessions. With the support of the nurse at the health centre,
and the online support, Louise was able to curb her drinking and
moved away from thoughts of suicide. She kept in touch with the
peer support group and was able to see a mental health counsellor in
her community every month (Mental Health Commission of Canada,
2017).
Caring for an aging population
More than three quarters of the population feel that Canada’s aging
population is a national concern. The underlying problem is the
increasing numbers of older Canadians proportionate to the rest of
the population and the impact this has on the health care system.
The cost of caring for an older population is significant, and caring
for this demographic is stretching resources. This situation poses
two questions: Does caring for a disproportionately large aging
population reduce resources and services available for everyone
else? Can the existing health care system provide mix, balance, and
availability of resources required to properly care for older
Canadians?
Statistics Canada predicts that between 2015 and 2021 the number
of older Canadians (over 65) will surpass the number of children
under the age of 14. By 2031 one in four Canadians will be over the
age of 65. This shift in demographics is caused by the baby boomers
(those born between 1945 and 1965) ge ing older, and the fact that
people are living longer (Statistics Canada, 2017a).
Advances in medical science and clinical practice have resulted in
people living longer—some with good health, but many others with
multiple chronic health problems requiring ongoing
medical/surgical intervention and support. Older Canadians use the
health care system more often, require more time, are more likely to
require expensive surgery such as a hip or knee replacement, or
need cataract surgery. Older Canadians are less likely to rebound
from some surgeries, often going on to require continued support at
home or in a long-term care facility. And as they age, the costs of
services and care rise.
Provider’s Time
On average, a healthy older Canadian does not visit the doctor more
frequently than anyone else, but older Canadians with multiple
chronic conditions do, and they require longer visits with their
provider.
Older Canadians (or older adults) rarely have just one health issue
when they visit their provider. The presenting problem may be joint
pain, indigestion, or generalized aches, but this invariably evolves to
the practitioner having to investigate more than one health issue,
which is difficult if the patient has a designated time frame with the
practitioner. In addition, older Canadians are more likely to be on
multiple medications that require constant updating and
monitoring. This means there is less provider time to spend with
other patients. On average, a physician or nurse practitioner can see
about 24 patients in an afternoon (in a 4-hour time frame, averaging
a patient visit every 10 minutes). This is reasonable with
intermediate and minor health problems. Older Canadians are likely
to take much longer if there are multiple health issues to deal with,
perhaps 30 minutes per visit; this would reduce to 12 the number of
patients (on average) a primary care provider could see in a 4-hour
afternoon.
Multidisciplinary health care teams as well as nurse practitioners
(NPs) and physician assistants (PAs), have greatly improved access
to primary care for older Canadians. Services include those managed
by specialized nurses, dieticians, counsellors, diabetic and
hypertension clinics, and monitoring chronic conditions remotely
(e.g., lab values for individuals on blood thinners).
Timely access to specialists is difficult for all Canadians, with longer
waits for some surgical procedures such as hip and knee surgery,
primarily required by older adults. Wait times vary within
communities and also within provinces/territories, but often
benchmark wait times are not met (the benchmark time frame is 6
months for elective joint replacements, primarily hip and knee; and
48 hours for urgent surgery for fractured hips). Repairs for hip
fractures are the most common urgent surgical procedures
performed in Canada, with approximately 30,000 done each year. Of
interest is a research paper released in June of 2018 that found that
urgent surgery for a fractured hip, if done within 24 hours,
significantly lowered the rate of morbidity and mortality. Waiting
g y y y g
longer is associated with medical complications such as blood clots
(Pincus, Wasserstein, Ravi, et al., 2018).
There is an ongoing shortage of gerontologists across Canada,
although primary care practitioners often try to fill the gap. For the
most part, primary care physicians and nurse practitioners provide
medical care in long-term care facilities, referring residents to
specialists as required. They may take extra training in gerontology,
or supplement their knowledge base with courses online, or a end
specialized gerontology conferences.
What’s Next?
For the foreseeable future Canadians will continue to live longer,
many with more complex medical, physical, and cognitive health
problems. The number of aging Canadians with cancer is expected
to increase approximately 40% by 2030. This will necessitate a
corresponding increase in cancer treatment services, which are
already stressed. It is estimated that the number of Canadians living
with dementia will rise by an alarming 60% over the same time
frame. Of note, the risk of developing dementia doubles every 5
years after the age of 65. Most long-term care facilities have “locked
units” providing care for individuals with advanced dementia,
which involves more intensive nursing care and supervision. There
are innovative strategies and programs to promote memory comfort
and improve the quality of life for individuals with dementia, but
their care is still demanding and costly.
Long-term care facilities face severe shortages including beds (as
noted earlier) and health human resources. Private facilities are
available, but are well beyond what many families can afford.
The number of Canadians that cannot manage independently is
expected to double within the next 30 years. More and more families
will have to assume responsibilities for their loved ones with
dementia and other chronic conditions, responsibilities that are
frequently too difficult to manage. Currently an estimated one-third
of Canadians are designated as caregivers.
Thinking it Through
With an aging population, informal caregivers increasingly must
provide care for older family members. Almost 17% of these
caregivers report stress related to this role.
The Problems
The demand for home care services (both short term and long term)
has grown, but services have not kept pace with the demand. Across
Canada, one in every six adults is receiving some level of home care
services, the majority of those older Canadians. In 2014 those
between the ages of 15 and 34 accounted for 29% of service usage;
those between 45 and 64 accounted for 31%; those between 65 and 74
used 13%; and those over the age of 75 used 27% of home care
services (Statistics Canada, 2014).
Older Canadians want to maintain their independence for as long
as possible. Living at home with the proper support is often a be er
option to living in long-term or continuing care. Although home care
is more cost effective, many problems exist: insufficient numbers of
trained home care workers; limited provincial and territorial
insurance coverage for these services; inconsistent, poorly
coordinated, and poor-quality care; and scheduling or
communication problems between caregivers (Statistics Canada,
2014).
The Future
All jurisdictions have a mandate to improve home care services with
the targeted funding received from the Federal Government in 2017.
This includes developing policies, procedures and strategies to
address problems, most of which are discussed above. It is
important to remember that the demographics of an older
population vary with jurisdictions, resulting in variation in funding
formulas as well as the specific needs and concerns in each
community. There are some common goals that most provinces and
territories want to achieve, most depending on an adequate financial
base. These include but are not limited to the following:
Thinking it Through
There are increasing calls for public health insurance plans to add
comprehensive home care services and medications to insured
services. However, if implemented, these additions will cost
enormous amounts of money that will compromise funding for
other services.
Funding
Although the provinces and territories provide some coverage to
vulnerable populations (e.g., low-income individuals, and older
adults), Canada has neither a universal pharmacare program nor a
national catastrophic drug plan, leaving a large portion of Canadians
unable to pay for the medications they need. As discussed in
Chapter 2, the Federal Government finances drug plans through
various agencies for selected Indigenous populations, veterans, some
members of the Royal Canadian Mounted Police, and federal
offenders; Citizenship and Immigration Canada covers drug costs
for specified refugee claimants, and the Department of National
Defence, for members of the Canadian Forces. There are still many
Canadians who carry no private drug insurance and suffer financial
hardship when they need medications.
The Future
The debate about a national pharmacare system and why Canada
doesn’t have one is important and frequently debated in the media.
Although the need for a national drug plan has long been
recognized and the topic is under consideration by all levels of
government, there are no concrete plans in place. The need for a
national strategy, however, is being considered at the federal level
(see Chapter 1). A national pharmacare plan would offer many
benefits, including the creation of a central agency to control the
price of drugs and to monitor the quality and price of new drugs
introduced to the market.
Cannabis
Cannabis became legal in Canada in October 2018 (see Chapter 8).
Concerns over decriminalizing recreational cannabis will continue to
evolve; some will be successfully addressed, and others will not, at
least in the short term. Issues are multiple, and include the
following:
Practitioner Retention
Retaining medical and nursing staff is a challenge, however, and
turnover is high. Living in an isolated area is a significant deterrent,
especially when they are away from their families. Access to ongoing
education/professional development is a concern, although there are
more educational programs available online.
In an effort to retain practitioners in northern regions, provincial
and territorial governments offer financial, tax, and other benefits as
incentives (e.g., longer paid vacations, living allowances, educational
opportunities). Nurses usually work in remote communities on a
rotational basis which vary. Short rotations of 3 weeks in and out of
communities managed by Indigenous Services Canada. Otherwise, 1
to 3 months per rotation are usual with nurses, although at times a
nurse may be asked to stay longer if there are staffing shortages.
Nurses often establish bonds with individuals in their community,
which draws them back. The nurses provide care described as from
“birth to death” acting not only as primary care providers, but as
counsellors, and advisers to the people in the community.
Related Organizations
The Canadian Indigenous Nurses Association (CINA) provides support
and resources for nurses with an interest in Indigenous health. One
of the association’s many and ongoing objectives is to encourage
interest in Indigenous health and to facilitate the continuing
development of courses, within the Canadian health care system, on
Indigenous health and cultural safety in nursing. Another objective
is to make both the Canadian and international communities aware
of the health needs of Indigenous people in Canada and promote
Indigenous involvement in making decisions that impact their health
care services. The CINA partners with organizations, such as the
Canadian Nurses Association, to promote Indigenous health. The
CINA also collaborates with the Canadian Network of Nursing
Specialists, linking with 45 national associations each representing a
specialized area of nursing. This provides for the sharing of
specialized knowledge, philosophies, and concerns. The expertise
concerning Indigenous health care, traditions, and cultural practices
shared by the CINA go a long way to helping nurses across the
country provide culturally safe care across the country.
Box 10.1
The Sioux Lookout Meno Ya Win Health Centre.
Andaaw’iwewin egkwa Mushkiki (Traditional Healing Practices
and Medicines) is a culturally sensitive program that incorporates
traditional practices, principles, and spiritual healing ceremonies
that usually take place in a specially designed ceremonial room and
include vigils, smudging, and healing circles. The room has an open
fire pit with circular seating. Ya Win Health Centre has a roster of
traditional practitioners who are available to patients requiring their
services. These practitioners must go through a process of
certification administered by a traditional practitioners commi ee.
In addition, Indigenous hospital patients can choose to be served
traditional meals (game and fish), which are exempt from the
inspection policies imposed on other food.
The hospital’s diagnostic services include fluoroscopy,
ultrasound, digital mammography, and CT scans. A ached to the
health centre is an extended care facility and a medical withdrawal
unit to treat patients withdrawing from drug and alcohol addiction.
Sources: Sioux Lookout Meno Ya Win Health Centre. (n.d.). Retrieved from
h p://www.slmhc.on.ca/; Ontario Nursing Jobs. (2010); Sioux Lookout Meno
Ya Win Health Centre. Retrieved from h p://ontarionursing.ca/featured-
employer-401.html.
Thinking it Through
Mercedes, a 32-year-old New Brunswick resident, was brought into
the emergency department at the Foot Hills Medical Centre in
Calgary. She had been hit by a car and sustained a serious and
painful leg injury. By the time Mercedes was seen in the emergency
department (ED), she was semiconscious and incoherent—a
condition not congruent with her injury. The nurses located her
provincial health card in her wallet and accessed her electronic
health record (EHR), which revealed she was diabetic and allergic to
codeine.
Advantages of computerization
Hospitals in Canada use electronic systems, either fully or partially.
Almost every phase of the hospital experience, from admission to
discharge, is supported electronically. Advantages impact care
providers, hospital staff, and patients alike.
Patient charts in most facilities are completely computerized,
although some departments retain a selection of hard-copy
documents in a patient’s chart/binder on the patient care unit.
Computerized Physician/Practitioner Order Entry (CPOE) is now
common in hospitals, whereby the provider enters all patient orders
into the computer allowing the facility's integrated software system
to send each order to the appropriate destination (e.g., medication
orders to the pharmacy, blood work to the laboratory, diet orders to
nutritional services). Electronic systems also function as safeguards
to patient care, identifying and tracking infections, and notifying
appropriate individuals of medication errors and other adverse
events. Computerized order entry software alerts physician
prescribers to the potential for drug-to-drug interactions, if the
patient is allergic to a prescribed medication or its ingredients, when
tests have been duplicated, or if there is a critical lab value on a
patient.
In newer hospitals, patients can change the room temperature,
control the lighting, call their nurse electronically, or even video chat
with their nurse, and read their medical charts on a bedside monitor.
A patient’s computerized chart is accessible at the bedside, enabling
care providers to view orders, lab results, medications, and enter
notes at point of care. There is either a computer at the patient’s
bedside, or a mobile device called a WOW (workstation on wheels)
that provides mobile access to the patient’s chart. Many hospital
pharmacies prepare medications using robot technology. Once
prepared, the patient’s medications are transferred to an electronic
medication cabinet where nurses can retrieve the patient’s
medications when they are due to be given.
Three of the most commonly used hospital information systems
are Cerner, Epic, and Meditec. Often hospitals use different
operating systems that are incompatible with those used by care
partners, thus impeding connectivity.
Hospitals are continually working to find interfaces that will allow
computer systems among a variety of care partners to “talk” to each
other, using interfaces such as H17. This facilitates the transfer of
information from point of entry to an intended destination. Consider
Zac who is a complex care patient with several organizations caring
for him at home. Zac comes into the emergency department, and his
demographic information is entered into the hospital system. The
hospital system will automatically contact surrounding
organizations to see if he is in their system. If he is in the system, the
computer through the H17 interface will send his community care
plan to the ED. With that information the physician may be able to
send him back home, knowing that he has the proper supports in
place. This type of coordination of services is sometimes referred to
as Transitions of Care.
Security protocols
All hospitals have security protocols, procedures, and policies that
all employees, physicians, and care providers are expected to be
familiar with, and adhere to. The employee, not the security system,
is more likely to be responsible for a security breach. The potential
harm that can result from one mistake related to a security breach is
far reaching. Moreover, harm is not likely limited to one computer,
but an entire system. It is important for employees to not only follow
the rules, but to always be alert for anything suspicious that might
lead to a virus infection or entry for a hacker.
Most larger hospitals now have an entire department dedicated to
digital security. They sometimes test employees’ awareness and how
well they scrutinize internet sites, emails, and messages. For
example, some facilities conduct what is called a “phishing
expedition” to see how employees respond to a bogus email with an
inviting link (e.g., sale of equipment in the hospital with a link to
details of the sale). One hospital had over 60% of their employees
click on the link, which easily could have contained a virus. The link
brought them to the IT department. There were hidden clues within
the link and email that the IT department thought employees would
have taken the time to check out, such as subtle differences in the
hospital logo, and language that just might seem “off” to the
employee.
For the most part, hospitals have several separate networks: one
that is external and for the public (such as Wi-Fi that patients and
visitors can log onto); one internal for staff to use in carrying out
professional responsibilities; and one that is more secure, providing
access to highly confidential information including patients’ charts.
Hospital employees who want to use their own electronic devices in
the hospital must give the IT department permission to scan their
devices for viruses, and allow the IT department access to their
devices at any time should they think there is a threat. The protocol
is called mobile device management.
Hospital IT security has software that continually scans for
security breaches within the hospital, and can identify individuals
a empting to access charts and other information for which they do
not have clearance. Only a care practitioner within the patient’s
circle of care is allowed to access that patient’s health information.
Upon request, IT will also flag the charts of patients in the public
domain (called VIPS or very important persons) to ensure that only
individuals sanctioned to access that person’s health information can
do so. For example, if a well-known actor or other celebrity was
admi ed, some hospital staff might not be able to resist having a
quick look at the person’s reason for admission. Any staff member
breaching this protocol is usually terminated on the spot for
unethical behaviour,
If a facility is hacked, it is essential for the hospital to respond
quickly, assess the damage, and report any breaches to the proper
authorities. Sharing information related to hacking a empts or
actual hacks with other facilities can limit the harm done. If a
hospital system is hacked and/or infected with ransomware, the
entire facility may need to be shut down temporarily, including the
cancellation of patient appointments, tests, and surgeries. In
addition, all individuals believed to be compromised must be
notified of the incident and potential risks. A facility can never
assume its IT systems are safe. A frequently heard quote puts things
into perspective, claiming that with respect to cyberhacking there are
only two types of facilities: those that know they have been hacked,
and those that don’t.
Doctors
The majority of physicians work in an electronic environment, with
some elements of their practice paper-based, a few still using a mix
of paper and electronic charts. EMRs have proven to vastly increase
the efficiency or productivity of a medical practice. Although
virtually all physicians are using computers for scheduling
appointments, advances in software are now offering self-scheduling
programs. An example is an organization called Click4Time, a self-
scheduling system that is growing in popularity and has won
awards sponsored by the CIHI for its online appointment and
resource booking system.
A growing number of Canadian physicians have a practice
website, offering patients access to their health information through
secure portals. The patient can review their medication profile, lab
and diagnostic test results, and immunization history, among other
things. Some portals allow the patient to exchange secure e-mail
with the health care team, change contact information, request
prescription refills, and access educational materials.
The major laboratories in Canada now offer websites where
patients can book appointments for lab tests online, making the
process easier and more convenient for both provider’s offices and
patients. Shortly after results are processed, most labs return them
electronically to the ordering provider as well as allowing online
patient access to their results. Shoppers Drug Mart Corporation has
a Health Care Portal, designed to provide selected Canadian health
care providers (e.g., doctors, nurse practitioners) with access to drug
reimbursement information and other clinical tools (e.g., health
information, handouts about selected conditions). Individuals can
also log in to their Shoppers Drug Mart site (similarly offered by
other pharmacies) and order prescription refills online.
In underserviced areas, physicians are using secure e-mail and
video conferencing to connect to patients, particularly in Canada’s
north. Video conferencing is valuable in assessing and treating
patients with a number of health problems ranging from those with
mental health and addiction issues and chronic diseases, to children
requiring speech therapy. Even in urban se ings, video conferencing
is being used (Case Example 10.2).
Case Example 10.2
Marc, who lives in Cape Dorset, was discharged from the hospital in
Iqaluit following a heart a ack. He also has diabetes and
hypertension. Follow-up appointments with his cardiologist (who
practises in O awa) were arranged through video conferencing. The
doctor was able to assess Marc’s progress, and if needed, would
bring Marc back to Iqaluit for further investigation and treatment.
Provider/Patient Relationships
Social media has significantly impacted the physician/patient
relationship, offering among other things, improved communication
opportunities, and improved access to health information. For
example, some providers have portals through which patients can
access their own health information, communicate with various
providers, and find links to more detailed information about their
health conditions, treatment options, and potential treatment plans.
Individuals often come to appointments more informed about their
health problem, having done online research. However, individuals
who go to see their health provider armed with volumes of health
information downloaded from the internet with the expectation that
their provider will have time to review it with them, may well be
disappointed. Because of limited appointment times, their provider
may dismiss the information presented.
Individuals can look up online information about their physicians
and other providers on rating websites and submit comments.
Information on these websites may or may not always be accurate.
Sometimes dissatisfied individuals will post opinions and relate
experiences that are more subjective in nature than fact-based
(Ventola, 2014). The wait list for procedures at hospitals can also be
viewed. Many hospital emergency departments also post wait times
online in terms of when the person can expect to be seen. This of
course does not relate to acute conditions, as patients are triaged
according to the urgency of their condition.
Support Groups
Support groups available through social media, usually initiated by
providers or health organizations, can be an important part of a
person’s overall treatment plan. Support groups typically target
specific problems such as grief, mental health and addiction
(through e-mental health, see Chapter 7), chronic diseases, or cancer.
They may be facilitated by a person within the group or be led by a
health professional. These groups help participants cope with their
health problem, provide practical advice, support, and impart a
sense of belonging and companionship—especially important for
individuals for whom physical mobility is a challenge, or who live in
rural or more remote communities (Bourque, Hornung, Lee, et al.,
2013).
Risks
There are always risks a ached to obtaining information online, both
concerning the reliability of the information, and also how the user
interprets and uses the information. Confidentiality is another
concern. A large segment of information posted online is within the
public domain. Even health information posted/available on secure
websites is subject to security breaches. Health professionals are
responsible for safekeeping health information they have access to,
and must think carefully before posting any such information. Even
posting what a health professional thinks is nonidentifiable health
information can sometimes be traced to the person.
As mentioned above, Information acquired from the internet may
or may not be accurate. Research articles on the internet can be
perfectly legitimate based on appropriately conducted research.
Other articles, however, are not credible. Differentiating between the
two is sometimes difficult. Numerous journal articles that appear to
be legitimate may well be published by an organization representing
a certain product, or an organization promoting a drug or a
procedure. Inaccurate information accepted as fact and used by both
patients and professionals can result in negative consequences
(Bourque et al., 2013; Emory University, 2018).
Summary
10.1 Despite the implementation of strategies to address the
issues of care of those with mental illness, problems remain.
Mood disorders and substance and alcohol misuses are
among the most common mental health disorders, with the
use of opioids rapidly increasing. Contaminated drugs are,
in part, responsible for an alarming number of deaths from
overdoses. Canada-wide strategies include the availability of
Narcan kits to reverse the effects of overdoses, and the
establishment of safe injection sites. Ensuring appropriate
and timely treatment (including inside correctional facilities),
reducing the stigma of mental illness, and addressing
challenges such as suicide and homelessness remain
priorities.
10.2 Older Canadians make up a significant proportion of the
population. With advances in technology and the use of
more effective medications, many are living longer, but with
one or more chronic conditions that require coordinated care
within the community se ing. In 2017 the Federal
Government targeted millions of dollars to provinces and
territories both for mental health and home care initiatives.
Jurisdictions determine what programs and services are most
effective in providing home care services used most by older
Canadians.
10.3 Home care is recognized as a critical component of primary
health care. The current philosophy is that individuals can
receive be er and more cost-effective care at home. In
addition, people cared for in the home appear to recover
faster and are less likely to acquire an institution-based
infection. A significant problem is an acute shortage of home
care providers ranging from nurses to personal support
workers. All jurisdictions have a mandate to improve home
care services with the targeted funding received from the
Federal Government in 2017. This includes developing
policies, procedures, and strategies to address problems.
10.4 Canada does not have a national drug plan. Provinces and
territories do provide some coverage for Canadians over age
65 and for vulnerable groups (usually income related).
Nevertheless, an overwhelming number of Canadians cannot
afford prescription drugs. Cannabis became legal in Canada
in October 2018. Provinces and territories can decide how the
sale of cannabis is regulated as well as the appropriate age
for use. Concerns remain with respect to use when driving,
in the armed services, and also the workplace. Packaging,
controlled by the Federal Government, is to remain plain.
10.5 Indigenous Canadians face inequities not experienced by
other Canadians. Largely reflected in the determinants of
health, these include unemployment, poor living conditions,
poverty, marginalization, and fragmented health care. Many
communities have assumed responsibility for delivery of
health care with positive outcomes.
10.6 Electronic health records are used in most facilities across
Canada, in primary care as well as in hospitals. All facilities
have security measures in place to protect health
information; larger hospitals have an entire department
devoted to identifying threats from within and outside of the
facility. Employees who do not adhere to policies and
protocols, and who are not alert to cyber intrusions pose a
significant risk. Something as seemingly benign as clicking
on an unrecognized link in an email can expose the entire
hospital to a cyber-a ack.
10.7 Cost containment is a necessary reality if Canada’s health
care system is to survive. Applications such as the LEAN
strategy are being implemented in health care facilities
across the country.
10.8 Social media is an umbrella term referring to any form of
electronic communication exchange among a variety of
users. Social media is widely used in healthcare offering
many benefits, from point-and-click access to vast amounts
y p
of health information to improved connectivity and
communication among patients, providers and health care
facilities. There are however, always risks not the least of
which is related to the reliability and accuracy of information
obtained online and how the user interprets and uses the
information. Security of health information posted and/or
exchanges online is also a concern.
Review Questions
1. Identify three factors that affect a person’s mental health.
a. Why does the stigma of mental illness prevent
individuals from seeking assistance and support?
b. Do you think that mental health services in your
community are adequate? Why or why not?
2. What major challenges do we face in providing health care to
Canada’s increasingly aging population?
a. What factors have contributed to an older
population in Canada?
3. Describe the reasons a shortage of regulated nurses may exist
in one region and not another.
4. How is the government encouraging an increase in available
home care services?
5. Why do some Canadians have no drug coverage?
6. Explain some of the major reasons behind unreasonable wait
times for medical care.
7. Outline four areas in which the health of Indigenous
Canadians falls below national standards.
8. Discuss three benefits of the use of electronic health records.
9. What are some of the major concerns regarding the security
of health information systems in hospitals?
10. How can hospital employees reduce the risks of an IT
security breech?
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APPENDIX
Declaration of Alma-Ata
II
The existing gross inequality in the health status of the people
particularly between developed and developing countries as well as
within countries is politically, socially and economically
unacceptable and is, therefore, of common concern to all countries.
III
Economic and social development, based on a New International
Economic Order, is of basic importance to the fullest a ainment of
health for all and to the reduction of the gap between the health
status of the developing and developed countries. The promotion
and protection of the health of the people is essential to sustained
economic and social development, and contributes to a be er quality
of life and to world peace.
IV
The people have the right and duty to participate individually and
collectively in the planning and implementation of their health care.
V
Governments have a responsibility for the health of their people,
which can be fulfilled only by the provision of adequate health and
social measures. A main social target of governments, international
organizations, and the whole world community in the coming
decades should be the a ainment by all peoples of the world by the
year 2000 of a level of health that will permit them to lead a socially
and economically productive life. Primary health care is the key to
a aining this target as part of development in the spirit of social
justice.
VI
Primary health care is essential health care based on practical,
scientifically sound and socially acceptable methods and technology
made universally accessible to individuals and families in the
community through their full participation and at a cost that the
community and country can afford to maintain at every stage of
their development in the spirit of self-reliance and self-
determination. It forms an integral part both of the country’s health
system, of which it is the central function and main focus, and of the
overall social and economic development of the community. It is the
first level of contact of individuals, the family and community with
the national health system, bringing health care as close as possible
to where people live and work, and constitutes the first element of a
continuing health care process.
VII
Primary Health Care
IX
All countries should cooperate in a spirit of partnership and service
to ensure primary health care for all people since the a ainment of
health by people in any one country directly concerns and benefits
every other country. In this context, the joint WHO/UNICEF report
on primary health care constitutes a solid basis for the further
development and operation of primary health care throughout the
world.
X
An acceptable level of health for all the people of the world by the
year 2000 can be a ained through a fuller and be er use of the
world’s resources, a considerable part of which is now spent on
armaments and military conflicts. A genuine policy of
independence, peace, détente and disarmament could and should
release additional resources that could well be devoted to peaceful
aims and in particular to the acceleration of social and economic
development of which primary health care, as an essential part,
should be allo ed its proper share.
The International Conference on Primary Health Care calls for
urgent and effective national and international action to develop and
implement primary health care throughout the world and
particularly in developing countries in a spirit of technical
cooperation and in keeping with a New International Economic
Order. It urges governments, WHO and UNICEF, and other
international organizations, as well as multilateral and bilateral
agencies, nongovernmental organizations, funding agencies, all
health workers and the whole world community to support national
and international commitment to primary health care and to channel
increased technical and financial support to it, particularly in
developing countries. The Conference calls on all the
aforementioned to collaborate in introducing, developing and
maintaining primary health care in accordance with the spirit and
content of this Declaration.*
A
Accredited program: A program that meets standards requisite for
its graduates; usually, the standards are set by the profession’s
governing body, which may be national or provincial or
territorial.
Act: A comprehensive body of laws passed by Parliament or a
provincial or territorial legislature.
Active euthanasia: The taking of deliberate steps to end a dying
person’s life.
Active ingredients: Those ingredients in a drug that have
therapeutic value meant to cure, palliate, or otherwise treat a
health problem.
Advance directive: A legal document that specifies the nature and
level of treatment a person would want to receive in the event of
later being unable to make those decisions. Also called a living will
or treatment directive.
Affiliating body: An association that provides, among other things,
direction, support, continuing education, and networking
opportunities for its professional members (who may be regulated
or nonregulated).
Allied health professional: A health care provider other than a
doctor, nurse, or, according to some sources, a pharmacist or
dentist who provides supportive health care, including direct
patient care, technical care, therapeutic care, and support services.
Alternate levels of care (ALC): Inpatient care in a facility or part of a
facility in which the level of care provided meets the physical,
mental, and emotional needs of the patient.
Aseptic technique: A procedure performed under sterile conditions
to reduce the risk of infection.
Autonomy: The right to self-determination.
B
Beneficence: The act of doing good or being kind.
Block transfer: One payment from the federal to the provincial and
territorial governments to cover all services.
Branch: A division of a main office offering extended or supportive
functions.
Bureau: Government department responsible for a specific entity or
duty.
C
Canada Health Act: Legislation passed in 1984 that governs and
guides the delivery of equal, prepaid, and accessible health care to
Canadians.
Capitation-based funding: A funding formula to pay physicians
who participate in some type of primary health care reform
group. The doctor receives a set amount (determined by the age
and health status of each patient) for each rostered patient per
year.
Cardiovascular disease: Disease that affects the heart and vascular
system (i.e., blood vessels).
Catastrophic drug costs: Prescription drug costs that cause undue
burden on individuals with serious health conditions or illnesses.
Cerebrovascular disease: A number of conditions that affect the
flow of blood to the brain, the most serious of which is a stroke.
Civil law: A legal system in which laws governing civil rights and
relationships within society, between people and property, and
within families are wri en rather than being determined by
judges.
Code of ethics: A set of values and responsibilities serving to guide
the behaviour of the members of an organization or a profession.
Common law: Laws established over time by judges based on
decisions made on similar cases; sometimes referred to as case law.
Community-based care: Care provided for the client in the home
(e.g., incorporating visits from nurses or physiotherapists), or on
an outpatient basis rather than in the hospital or another health
care facility.
Compassionate interference: The act of imposing treatment against
a patient’s will when deemed in the best interests of the patient.
Compensation: That part of the health–illness continuum in which a
person is neither in good nor poor health, is able to accommodate
a malady, and is continuing on with daily life.
Confidential: Kept private or shared only with authorized
individuals (e.g., in health care, shared only with those authorized
to have health information about a patient).
Conflict of interest: The possible clash of two or more concerns. For
example, a personal financial interest in a business may influence
one’s professional decisions.
Constitutional law: The area of law dealing with legislation derived
from or related to Canada’s Constitution.
Continuity of care: Health care based on the treating practitioners
having all required information to optimize the care the patient
receives. Having access to the individual’s health records and
maintaining excellent communication among all parties involved
in the patient’s care are ways to ensure continuity of care.
Contract law: The branch of law dealing with agreements between
parties, including the interpretation or enforcement of agreements
when there is a dispute.
Controlled act: An act that, as specified in the Regulated Health
Professions Act, may be performed only by authorized regulated
health care providers.
Controlled Drugs and Substances Act: Federal legislation addressing
Canada’s drug laws, including a classification system for drugs.
Copayment: A predetermined dollar amount or percentage of the
cost of a health care service or medication that an individual must
pay.
Criminal law: The field of law dealing with crimes against the state
or against society. Criminal law defines offences and controls the
regulations concerning the apprehension, charging, and trying of
those believed to have commi ed a criminal offence.
Culture: Common elements of a social group, including its beliefs,
practices, behaviours, values, and a itudes. Culture can relate to a
society or to subgroups within a society.
D
Deductible: The amount of money that an individual or family is
required to pay toward health care costs before an insurance plan
will take over.
Delegated act: A controlled act that a physician authorizes another
health care provider, either regulated or unregulated, to do in his
or her stead and under supervision.
Delisted: The removal of an item from a list or a registry. In Canada,
the term is frequently used when a medical service is no longer
considered medically necessary and is removed from the
government’s list of insured services.
Deontological theory: An ethical theory that calls for a moral and
honest action to be taken, regardless of the outcome.
Disability: A physical or mental incapacity that differs from what is
perceived as normal function. A disability can result from an
illness or accident or be genetic in nature.
Disease: A disorder or medical condition affecting a system or
organ. The condition can be mental, physical, or genetic in origin.
Disease also refers to a deviation from how the body normally
functions.
Disease burden: The impact of a health problem, measured by
financial cost, mortality, morbidity, or other indicators.
Disease prevention: Used in conjunction with health promotion.
Information initiatives aimed at encouraging individuals,
especially those in high-risk population groups (e.g., with a family
history of diabetes or heart disease), to adopt strategies to prevent
diseases.
Dispensing fee: A service fee charged by a pharmacy for dispensing
a prescription medication (i.e., reading the prescription and
preparing the medication for the patient).
Divine command ethics: An ethical theory believing that ethical
philosophies and rules are set out by a higher power.
Double effect: Acting in a manner that brings about the most good
or the least harm.
Drug identification number (DIN): A unique number assigned to
each medication approved by Health Canada for use in Canada.
Duties: Obligations a person has in response to another’s claims on
them. A duty may result from a professional or personal
obligation or may relate to one’s own morals or values.
Duty of care: The obligation to act in a competent manner according
to the standards of practice.
E
Electronic health record (EHR): Health information collected by
more than one facility and shared electronically among health
care service providers (e.g., a doctor’s office, emergency
department, and pharmacy).
Electronic medical record (EMR): Health information obtained and
stored at one facility, perhaps a dentist’s, chiropractor’s, or
doctor’s office.
Eligible: Qualified for inclusion because of meeting certain criteria
or requirements.
Enhanced services: Optional health services, such as choice in
hospital rooms, enhanced medical goods and services, and
services not covered by the public health insurance system,
offered to the patient at a cost.
Ethical principle: An acceptable, usually highly valued and moral,
standard of human behaviour—for example, honesty,
truthfulness, and fairness.
Ethical theory: A framework of ideas that provides a template for
making decisions to justify a set of actions.
Ethics: The knowledge of and rules about behaving according to set
values, duties, and moral principles.
Etiology: The study of causes. In medicine, etiology refers to the
origin or cause of a disease.
Evidence-informed: Proven, through high-quality scientific studies,
to be effective.
Exacerbation: A period of time when a disease (usually chronic) is
active and the person has symptoms. Exacerbation may also refer
to an increase in the severity of a disease.
Extra billing: An additional fee, considered a contravention of the
Canada Health Act, charged to the user by a health care provider
for a service covered under the terms of a provincial or territorial
health insurance plan.
F
Fidelity: The quality of being faithful.
Fiduciary duty: A duty that binds professionals to act with honesty
and integrity and in the best interests of their patients, with regard
to their professional practice.
Fiduciary relationship: A relationship based on trust.
First ministers: The premiers of the provinces and territories.
Food insecurity: Poor or no physical or economic access to
nutritious foods required to maintain a healthy state.
Forensic psychiatric hospitals: Hospitals that assess and treat
individuals referred by the Canadian courts, and those requiring a
secure inpatient facility due to a risk for harm to self or others.
Formulary list: A list of prescription medications (often generic
brands) selected for coverage by a public or private health
insurance plan.
G
Geriatrics: The branch of medicine dealing with the physiological
characteristics of aging and the diagnosis and treatment of
diseases affecting the aged.
Good Samaritan law: A law protecting individuals who a empt to
offer help to a person in distress.
H
Health accord: A legal agreement between the federal and
provincial and territorial governments on health care funding.
Health behaviour: The activities a person engages in to acquire and
maintain good physical and psychological health.
Health beliefs: Things people believe to be true about their personal
health and susceptibility to illness and about illness, prevention,
and treatment in general.
Health care provider: A person who has graduated from a health-
related college or university program and is accredited by a
professional or regulating body. Often the person must be
licensed by a provincial or territorial government.
Health indicators: Measurements that help to gauge the state of
health and wellness of a population.
Health model: A concept of an approach to care, including the
development of a treatment plan and involvement and
communication with a patient.
Health promotion: Initiatives that inform people about things they
can do to remain healthy and to prevent disease and illness.
Holistic: Whole. In health care, a holistic approach treats the whole
person, not an individual part of the person. For example, a
holistic approach to treating a person with a heart condition
would consider the patient’s emotional state, diet, and fitness
level, not just their heart problem.
Hospice: A facility that provides supportive and compassionate care
to individuals who are (usually) in the final stages of a terminal
illness. Care provider address the physical needs of patients
including pain management pain as well as the spiritual, social
and psychological needs of patients and their loved ones.
reaction: A response to a drop in blood sugar levels. The symptoms
may include mild weakness or dizziness; headache; cold, clammy,
or sweaty skin; problems concentrating; shakiness; uncoordinated
movements or staggering; blurred vision; irritability; hunger;
fainting; and loss of consciousness.
I
Implied consent: Consent assumed by the patient’s actions, such as
their seeking out the care of a health care provider, or their failure
to resist or protest treatment.
Incident report: A legal document outlining all relevant information
concerning any negative occurrence in the workplace.
Indigenous Peoples: Indigenous Peoples refers to the original
inhabitants of a land and their descendants. In Canada,
Indigenous refers to First Nations, Inuit and Métis people living
within Canadian borders.
Inequities in health: Unfair and unequal distribution of health
resources in relation to resources available and the population
involved.
Infant mortality: The death of an infant (i.e., within the first year of
life).
Informed consent: A formal agreement signed by a patient
consenting to a treatment, procedure, or test administered by a
health care provider after the patient has been fully informed of
all related risks and benefits.
Interprofessional collaboration: Multiple health care workers from
a variety of professions working together to deliver evidence-
informed, patient-centred health care.
Intersectoral cooperation: Joint action among the public, the
government, and nongovernment or community-based
organizations.
Intubate: The passing of a tube into a person’s trachea to facilitate
breathing.
Inuit: Indigenous Peoples in northern Canada, generally living
above the tree line in the Northwest Territories, Northern Quebec,
and Labrador.
Involuntary euthanasia: A person’s bringing about the death of a
dying person without the dying person’s consent.
L
Laparoscopic surgery: A type of surgical procedure in which a small
incision is made in the body, through which a viewing tube
(laparoscope) is inserted. A small camera in the laparoscope
allows the doctor to examine internal organs. Other small
incisions may be made to insert instruments to perform surgery.
Life expectancy: The number of years a population or parts of a
population are expected to live as determined by statistics.
M
Malpractice: Illegal, negligent, or substandard treatment (failing to
meet the treatment standards of one’s profession) by a medical
practitioner. Malpractice may be intentional or unintentional
wrongdoing that may or may not result in injury to a patient.
Medical Assistance in Dying (MAID): The taking of one’s own life
with means provided by a doctor.
Medically necessary: A clinical judgement made by a physician
regarding the necessity of a service provided under a provincial
or territorial health plan to maintain, restore, or palliate (i.e., ease
symptoms, such as pain, without curing the underlying disease).
Medicare: The informal name for Canada’s national health
insurance plan. Note that the term’s use in Canada differs from
that in the United States, where Medicare refers to a federally
sponsored program for individuals over the age of 65.
Morality: A code of conduct defined by a group of people, culture,
society, or religion. Individuals may have a moral code that
governs the way they live, behave, and interact with others.
Morals: A person’s beliefs about right and wrong regarding how to
treat others, and how to behave in an organized society.
Morbidity: The occurrence of disease or impairment resulting from
accidents or environmental causes—for example, the number of
people injured in a multiple-vehicle accident or the number of
people who have a particular disease, such as cancer (but who
have not died).
Mortality: The occurrence of deaths resulting from disease,
accidents, or environmental causes—for example, the number of
people killed in a multiple-vehicle accident or the number of
people who died from a particular disease, such as cancer.
N
Negligence: The failure of a health care provider, whether
intentional or unintentional, to meet the standards of care
required of their profession; also sometimes referred to as
malpractice, especially when resulting in harm or injury to the
patient.
Nonmaleficence: Doing no harm.
Nonprofit organizations (NPOs): Organizations that return surplus
revenue (profits) back to the facility for purposes of maintaining
or improving the facility and its operations; usually managed by a
board as opposed to private owners.
Non-status Indians: First Nations people registered in Canada’s
official record (the Indian Act of Canada), sometimes referred to as
treaty Indians.
O
Oral consent: Verbal agreement from a patient to undergo a
treatment, procedure, or test performed by a health care provider.
Orphan patient: A person without a family doctor.
P
Palliative care: Care for the dying. Palliative care services, offered in
the home or another facility (e.g., palliative care unit in a hospital
or a hospice), may include nursing care, counselling, and pain
management, and may involve those close to the patient.
Pandemic: A sustained, worldwide human-to-human transmission
of disease.
Passive euthanasia: The process of allowing a person to die by
removing life support or other life-sustaining treatment.
Patented drugs: Drugs that are legally protected from generic
production for a period of 20 years from the date of filing.
Paternalism: The a empt to control or influence another’s decision
regarding medical care. Paternalism does not honour the patient’s
right to autonomy.
Personal Information Protection and Electronic Documents Act
(PIPEDA): A federal act ensuring the protection of personal
information in the private sector.
Population health: A framework for gathering and analyzing
information about conditions that affect the health of a
population. The aim is to both maintain and improve the health of
the entire population and to reduce inequities in health status
among population groups.
Positron emission tomography (PET) scanner: A scanning device
that uses nuclear imaging techniques to obtain 3-D images of
parts of the body.
Power of a orney: A legal document naming a specific person or
persons to act on behalf of another in ma ers concerning personal
care, personal estate, or both.
Practice se ing: The context and environment in which health care
is delivered.
Prepaid health care: Access to medically necessary hospital and
physician services on a prepaid basis, and on uniform terms and
conditions.
Primary care: Front-line care, direction, and advice provided by
multidisciplinary health care teams. Primary care also involves
initiatives that seek to improve access to, quality of, and
continuity of care; patient and health care provider satisfaction;
and cost-effectiveness of health care services.
Primary care se ing: The organizational and physical environment
in which a person receives point-of-entry care (e.g., a doctor’s
office, walk-in clinic).
Primary health care: Health care with an emphasis on individuals
and their communities. It includes essential medical and curative
care received at the primary, secondary, or tertiary levels and
involves health care providers, as well as community members,
delivering, within the community, care that is cost-effective,
comprehensive, and collaborative (i.e., uses a team approach).
Primary health care reform: Changes to the delivery of primary
health care with the goal of providing all Canadians access to an
appropriate health care provider 24 hours a day, 7 days a week,
no ma er where they live.
Privacy: The patient’s right to control access to his or her body and
personal information.
Professional misconduct: Behaviour or some act or omission that
falls short of what would be proper in the circumstances.
Examples include deviating from a profession’s standards of
practice or violating the boundaries of a professional–patient
relationship.
Public health: The use of health information from a variety of
resources (e.g., Statistics Canada, the WHO, provincial, territorial,
and regional sources) to improve the health of communities.
Public health programs often carry out recommendations made
by population health studies.
Publicly funded health care: Health care services whose finances
are managed by the government or a government agency for the
good of the entire population.
Q
Qualitative research: A method of research that examines the way a
population group thinks and behaves. The analysis is largely
subjective in nature.
Quantitative research: A method of objective research that deals
with the measurement of data, such as the number of deaths from
cancer.
Quarantine: The enforced isolation of people having or suspected of
having a contagious disease.
Quarantine Act: Updated in 2005, this legislation gives the Federal
Government powers to assess individuals and detain those who
may pose a health risk to Canadians.
R
Rationalization of services: Any changes that increase the
effectiveness and efficiency of health care services—clinical,
administrative, or financial.
Refraction: Testing of the eyes to evaluate their ability to see. An
ophthalmologist or optometrist does a refraction to determine the
type of lens a patient needs in their glasses to maximize vision.
Refugee claimants: People who, feeling unsafe in their home
country, seek protection in another country.
Regulation: A form of law, made by persons or organizations (e.g.,
an administrative agency) awarded such authority within an act
(whether federal, provincial, or territorial), that has the binding
legal power of an act.
Regulatory law: Laws made not by Parliament or by a legislature
but by authorized persons or organizations to govern a particular
group; these laws are ultimately subject to the provincial,
territorial, or federal act that governs the administrative body,
organization, or tribunal.
Remission: A period of time during which a chronic disease is
neither active nor acute and the person has no obvious symptoms.
Renal dialysis: A process that filters waste and fluid from the blood
similar to the way kidneys do. Individuals whose kidneys are not
functioning must undergo this procedure several times a week to
stay alive while waiting for a kidney transplant.
Reserve: Land set aside by the Crown and designated for the use
and occupancy of Aboriginal people.
Residential care: Refers to living accommodations that offer a
variety of support needs, usually for older adults. These
accommodations include lodges (public or private), assisted
living, or supportive services in the community and long-term
care facilities.
Rights in health care: Entitlements, or things that can and should be
expected of health care providers and the health care system.
Rights may be tangible (e.g., the right to receive a vaccination
covered under the provincial or territorial plan) or intangible (e.g.,
the right to be treated with respect).
Risk assessment: The assessment or examination of a condition or a
situation to determine the potential harm or hazards (risk) related
to it (e.g., the risk for having an accident if you drive a car in a
snowstorm).
Role fidelity: In health care, meeting the reasonable expectations of
members of the health care team, patients, their families, and
employers by being loyal, truthful, and faithful; by showing
respect; and by earning and maintaining trust.
Rostering: The registering of a patient in a primary health care
reform group. Patients sign a nonbinding form stating that they
will seek care only from a specific doctor or primary care group.
Also called patient a achment or formal registration.
Royal assent: The final stage a bill passes through before becoming
law. Largely symbolic in nature, this approval is given by the
Governor General as a representative of the Crown.
S
Scope of practice: A range of skills, learned in school or through on-
the-job training that a practitioner can perform competently and
safely. From a professional perspective, legal parameters usually,
but not always, dictate what a practitioner may or may not do,
based on the profession’s education, training, and licensure.
Self-determination: The freedom to make one’s own decisions.
Self-imposed risk behaviours: Actions (such as smoking tobacco)
that a person willfully engages in despite knowing these actions
pose a danger to their health.
Severe acute respiratory syndrome (SARS): A severe form of
pneumonia that first swept across parts of Asia and the Far East
before spreading worldwide in 2003.
Sick role behaviour: A person’s response to disease or illness.
Removed from normal societal expectations and responsibilities,
the sick person may respond to situations differently from when
they are well. Sick role behaviour is usually temporary in nature.
Signs: Those things related to an illness that a person or examiner
can see (e.g., a rash).
Social movements: Advancements by advocacy or interest groups to
promote a common interest by acting together to influence public
policy.
Specialist: A physician trained in a specific field, usually concerning
body systems or organs—for example, cardiology, internal
medicine, orthopedic surgery—although some specialties (e.g.,
geriatrics) have a socioeconomic focus.
Status Indians: Individuals recognized by the Federal Government
as being registered under the Indian Act.
Statutory law: Wri en law, formally created or established by the
legislature.
Symptoms: Those things that a person feels that may relate to an
illness (e.g., fatigue, a headache). Symptoms are sometimes
referred to as clinical signs.
T
Telehealth: A telephone help system, usually available 24/7 and
funded by the provincial or territorial government, used to
provide professional health care advice to Canadians who cannot
readily access a doctor or other primary care provider.
Teleological theory: An ethical theory that defines an action as right
or wrong depending on the results it produces; also called
consequence-based theory.
Title protection: Legal restrictions around and guidelines for the use
of a professional title.
Tort: A civil wrong commi ed against a person or their property.
U
Upstream investments: Actions that can be taken to improve the
health of a population or to prevent illness when the potential for
a problem is first recognized.
Urodynamic: Referring to tests and assessments done to measure the
function of the bladder and urinary tract.
User charges: A fee imposed for an insured health service that the
provincial or territorial health care insurance plan does not cover.
V
Values: Something a person holds dear, such as a quality or a
standard by which to act or behave (e.g., loyalty, honesty).
Values history form: A document that helps people think about the
health care choices they would want made for them.
Virtue ethics: An ethical theory that operates under the belief that a
person of moral character will act wisely, fairly, and honestly, and
will uphold ethical principles.
Voluntary euthanasia: A person’s bringing about the death of a
dying person with the dying person’s consent.
W
Wellness: Good health and a sense of well-being on many levels (i.e.,
emotional as well as physical) as described or experienced by an
individual.
Wellness-Illness continuum: A method of measuring one’s state of
health at any given point in time. A person’s health state may
range from optimum health at one end to death at the other end.
Whistleblower: An individual who assumes responsibility for
publicly divulging information about a wrongdoing or
misconduct by another individual or an organization.
Workplace Hazardous Materials Information Systems (WHMIS)
legislation: A group of laws, rules, or statutes enacted by a
government (federal, provincial, territorial, or municipal).
Index
A
AAB See Audit and Accountability Bureau
Abortion 268b, 269–270
Accessibility 18–20, 19b
Accountability for health outcomes 172
Accredited programs 129
Accurate recording, importance of 231
Active euthanasia 261, 262b
Active ingredients in drugs 103
Activity-based funding 93
Acts (legislation) 208, 210b
Additional safeguards, in MAID 224
Administrative roles 135–136
Adult day programs 79
Advance directives 261, 262b, 264–265, 267b
Advance practice nurses 127
Advanced care directives 222
types of 222
Affiliating bodies 136
Age
ethical issues around 253b
of majority 229
Aging population, caring for 286–289
provider's time in 287
residential and long-term care accommodation in 288, 288b
ALC See Alternate levels of care
Allied health professionals 114
Allocation of resources 266–269
Allow natural death (AND) 260
Alma-ata, declaration of 311–314
Alma-Ata Conference, 1978 153–154, 154b
Alternate levels of care (ALC) 100
Alternative methods of paying physicians (APP) 105
Alternative practitioners 137
Ambulance services 78, 78b
Ambulatory care clinics 139
AND See Allow natural death
Annual Conference of Ministers of Health, 2005 28
Apology legislation 237–238
APP See Alternative methods of paying physicians
Armed forces, mental health care for 278
Aseptic technique 7
Assisted living accommodation 79
Assisted suicide, purpose of 261b
Assistive devices 80
Audiologists 133
Audit and Accountability Bureau (AAB), in Health Canada 38
Autonomy
defined 251
as a right 254–256, 256b
B
Beneficence 250–251
Biologic and Genetic Therapies Directorate, in Health Canada 41
Biology, as determinant of health 165, 165b
Bisexual 166
Blended funding 106
Block funding 92
Block payments 77b
Block transfer 15b
Blood products 9
Blueprint on Aboriginal Health 28
Boundaries
rationale for 259–260
in relationships, with patients 258–259, 259b
special, and relationships 258–259
at work 258–260
Brand-name drugs 103
British North America Act 213
British North American Act (1867) 2, 5, 11–12
C
CAD See Coronary artery disease
Canada, health care in
Canada Health Act 16–21, 16b
accords in 27–30
additional components of 21
after 21–30, 22–23b, 23t
commissioned reports 24–27, 24–26b
comprehensive coverage in 17, 17b
criteria and conditions of 16–20, 17b
EPF Act 14–16
initiatives in 30
interpreting 20–21, 20b
portability in 18, 19b
public administration of 16–17
significant events leading up to 14–16, 14–15b
social union 23–24
universality in 17–18, 18b
current issues and future trends 275–310, 275b
evolution of 2–11
division of responsibilities for health 2–3
healing practices, of Indigenous Canadians 3–6, 5b
hospitals, development of 7–8, 7b
medical care, origins of 3
nursing, in early health care 10–11
public health, concept of 10
volunteer organizations, in early health care 8–10
health insurance and 11–14
national, first a empts to introduce 11–12
political landscape 12
prepaid hospital care 12–13
prepaid medical care 13–14, 14b
history of 1–34
Canada Food Inspection Agency (CFIA) 47
Canada Health Act 2, 16–21, 16b, 220
accessibility in 18–20, 19b
accords in 27–30
additional components of 21
after 21–30, 22–23b, 23t
application of 220
commissioned reports 24–27, 24–26b
comprehensive coverage in 17, 17b
criteria and conditions of 16–20, 17b
EPF Act 14–16
health care rights under 252
health insurance plans under 58–59, 70–72
initiatives in 30
interpreting 20–21, 20–21b
legislation leading up to 15b
portability in 18, 19b
public administration of 16–17
services insured under 73
significant events leading up to 14–16, 14b
social union 23–24
universality in 17–18, 18b
Canada Health Infoway 109, 299–304, 300b
Canada Health Transfer (CHT) 27–29, 87
Canada Social Transfer (CST) 87
Canada Vigilance Program 43–45
Canada’s National-Provincial Health Program for the 1980s 15
Canadian Blood Services 9
Canadian Centre for Occupational Health and Safety (CCOHS) 214
Canadian Charter of Rights and Freedoms
health care rights under 221–222, 222b, 252–253
Canadian Health Information Management Association
(CHIMA) 135
Canadian Institute for Advanced Research (CIFAR) 155
Canadian Institute for Health Information (CIHI) 45–46
Canadian Institutes of Health Research (CIHR) 46, 46b
Canadian Medical Association 21–22
Canadian Medical Protective Association 232, 238
Canadian Mental Health Association 277
Canadian National Association of Trained Nurses 11
Canadian Pandemic Influenza Preparedness: Planning Guidance for
the Health Sector (CPIP) 53
Canadian Practical Nurse Registration Examination (CPNRE) 129
Canadian Red Cross Society 9, 9b
Cancer, as cause of death 201–202
Cannabis 292–293, 293b
sales 218
Cannabis Legalization and Regulation branch, in Health Canada 45
Capitated funding 93
Capitation-based funding 106
Cardiologists 125
Cardiovascular disease (CVD), as cause of death 202–203
Care partners, for indigenous health care 294–295
Caregivers, tax credits for 98
CAS See Children’s Aid Society
Case-mix approach 93
Catastrophic drug costs, provincial/territorial coverage of 103
Causes of death (Canada) 200–203, 201f
CCOHS See Canadian Centre for Occupational Health and Safety
CDAs See Communications disorders assistants
Cerebrovascular disease, as cause of death 203
CFIA See Canada Food Inspection Agency
CFOB See Chief Financial Officer Branch
Charting
by exception 231
narrative 231
CHCs See Community health centres
Chief Financial Officer Branch (CFOB), in Health Canada 38
Children’s Aid Society 10
CHIMA See Canadian Health Information Management Association
Chiropodists 131–132
Chiropractic medicine 116–117
Chronic diseases, health care costs of 89
CHT See Canada Health Transfer
CIFAR See Canadian Institute for Advanced Research
CIHI See Canadian Institute for Health Information
CIHR See Canadian Institutes of Health Research
CINA See The Canadian Indigenous Nurses Association
Circle of care 234
Civil law 209
Clinical nurse specialists (CNPs) 128
Clinics
make sense 141, 142b
types of 139–141
CNATN See Canadian National Association of Trained Nurses
CNPs See Clinical nurse specialists
Codes of ethics 236, 258–260
Commissioned reports 24–27, 24–26b
Common (case) law 209
Communication and Public Affairs Branch, in Health Canada 43
Communications disorders assistants (CDAs) 133
Community-based health care 114
Community-based mental health care 278
Community care 137–139, 138b
Community health centres (CHCs) 146–147
Compassionate interference 258
Compensation 193–194, 194f
Compensatory justice 252
Complaint processes, regulated professions and 122
Complementary and alternative practitioners 114–117, 116b
Confidentiality
breach of 234, 235b
concept of 234, 234b
Congenital Zika syndrome 52
Consent
for deceased organ donation 230, 230b
in emergency situation 229
express 227
implied 228
informed 223–224, 224b
oral 228
wri en 227–228, 228b
Consequence-based theory 249, 249b
Constitution Act
equalization payments under 88, 88b
health care under 58–59, 58b, 208
Constitutional law 208
Consultant 124
Continuing care 100–102
Continuity of care 253–254
Contract law 211
Controlled acts 120–121, 121b
exceptions of 120–121
Controlled drugs
illegal use of 215
legislation covering 215
prescribing 215
prescriptions and 215
Controlled Drugs and Substances Act 215, 216b
Controlled Drugs and Substances Directorate, in Health Canada 45
Convenience, clinics and 141
Convention on the Rights of Persons With Disabilities 186b
Conventional health care providers 114, 115t
Copayment
for ambulance services 78
for long-term care 101
Coping skills, as determinant of health 163–164, 163–164b
Coronary artery disease (CAD) 202
Corporate Services Branch, in Health Canada 38–40
Cost effectiveness, clinics and 141
Co age Hospital System 7b
CPNRE See Canadian Practical Nurse Registration Examination
Criminal law 211–212, 212–213b
Culturally safe health care 296–297, 297b
Culture
as determinants of health 167–168, 168b
influence on health beliefs 192
CVD See Cardiovascular disease
D
Data quality 135–136
Day care 154–155
Day surgery 97
Declaration of Alma-Ata 311–314
Deductibles 80, 82b
Delegated acts 121–122, 122b
Delivery of health care 86
Deontological theory 249, 249b
Departmental Secretariat, in Health Canada 40
Determinants of health 157–168, 158f
analysis of 169–170, 169f
biology and genetic endowment as 165, 165b
culture as 167–168, 168b
education and literacy as 160–161, 161b
employment and working conditions as 161–162
gender as 166–167
health services 165–166, 166b
healthy child development as 164, 164–165b
income and social status as 157–158, 158–159b
linking of 155
personal health practices and coping skills as 163–164, 163–164b
physical environment as 163
social environment as 162–163, 162b
social support networks as 159–160, 160b
Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 277
DIN See Drug identification number
Direct health care, provincial/territorial costs for 89, 89t
Disability
defined 185–187, 186b
rights of people with 186b
Disease
defined 185, 185b
prevention 152
Dispensing controlled drugs, in facilities 215
Dispensing fees 80, 82b
Distributive justice 252
Divine command ethics 250, 250b
Division of power 213–220, 213b
DNR (Do Not Resuscitate) protocols 260
Do Not Resuscitate requests 264–265, 264b
Doctors, shortage of 104
Double effect 250–251
Douglas, Tommy 1, 13
Drug coverage 292–293
funding for 292
future for 292
Drug identification number (DIN) 81b
Drug insurance plans 80–82, 81b
provincial/territorial plans 103
public vs. private 81
spending on 80
Drug laws 215–217
Drug misuse 280–281
actions taken against 281
Drugs
active ingredients in 103
advertising 219
brand-name 103
controlled 215
expenditures 102–103
generic 103
illegal 215
patented 103–104
prescription 216–217, 216b, 219
rising cost of 102–104
Drug-seeking behaviour 216, 216b
Duties 248, 254
Duty of care 248
litigation and 211
E
Eagle Feather 5b
Ebola virus 51–52
Education, as determinant of health 160–161, 161b
EHRs See Electronic health records
Electronic health information management 135–136
Electronic health records (EHRs) 299–304
cost of 109
defined 235
in hospitals 300–302
information requirements of 235–236
security of 301
Electronic medical records (EMRs)
advantages of 300–301
defined 235
doctors and 302, 303b
information requirements of 235
Eligibility, MAID and 223
E-mental health 286
Emergentologists 124
Emotional wellness 183
Employment
as determinant of health 161–162
mental illness and 284–285, 285b
Employment and Social Insurance Act 11
EMRs See Electronic medical records
End-of-life decisions, preparation for 264–265
End-of-life issues 222, 260–266, 261b
Enhanced services 75b
Environmental wellness 184
Epidemic 51
Epp, Jake 171
Epp Report, 1986 155
Equality of care 210b
Equalization payments 88, 88b
Established Programs and Financing (EPF) Act 14–16, 15b
Ethical principles
autonomy 251, 254–256, 256b
beneficence 250–251
breach of 251b
defined 250–252
double effect 250–251
fidelity 251–252, 252b
justice 252
nonmaleficence 250–251
respect 251
truthfulness 251, 256, 256b
Ethical theories 248–250
Ethics
codes of 236, 258–260
commi ees 260
consequence-based theory of 249, 249b
defined 246–248
deontological theory of 249, 249b
divine command ethics 250, 250b
and health care 245–274
teleological theory of 249
virtue ethics 249–250, 249b
at work 258–260
Etiology 183
Euthanasia 261–262, 262b
active 261, 261–262b
involuntary 261, 261–262b
passive 261, 261–262b
voluntary 261, 261–262b
Evidence-informed treatment 115–116, 116b
Exacerbation 185, 185b
Express consent 227
Extended health care services 21, 79
Extra billing 14, 21
F
Family Care Clinics (FCCs) 144
Family Health Teams (FHTs) 143–144
Family physicians 124, 278–279
FCCs See Family Care Clinics
Federal government
in health care 35–56
health transfer payments 87–88
role of 217
Fee-for-service (FFS) 105
FFS See Fee-for-service
FHTs See Family Health Teams
Fidelity 251–252, 251b
Fiduciary duty 225
Fiduciary relationship 251
Finances and resources 267–269, 268–269b
First ministers 23
First Ministers' Accord on Health Care Renewal, 2003 27–28
First Ministers' Meeting, 2000 27
First Ministers' Meeting on the Future of Health Care, 2004 28
First Nations and Inuit Health Branch, in Health Canada 40–41
First Nations Health Authority (FNHA) 295
Fiscal capacity 88
FNHA See First Nations Health Authority
Formal registration 145
Formulary lists 81, 82b
Fox, Terry 186–187b
G
Gay 166
Gender, as determinant of health 166–167
General practitioners 124
Generic drugs 103
Genetic endowment, as determinant of health 165, 165b
Genetic testing 270–271, 271b
Geriatricians 125
Geriatrics 125
Gifts, accepting 260
Global budget funding 106
Good Samaritan laws 239, 240b
Group homes 79
Gynecologists and Obstetricians (OB/GYNs) 125
H
Hall, Emme 13
Hall report 15b, 16
Hard-to-serve communities and populations 144
Harm reduction sites or clinics 140, 140b
Hawking, Stephen 194–195
Hazardous Products Act 215
Healing circle, configuration of 4
Health
of Canadian 199–203
defined 180, 181b
determinants of 155, 169–170, 169f
indigenous wholistic theory for 188–189
individual and 179–206
inequities in 153
key concepts of 181
perceptions of 189–191
Health accords 88
Health behaviour 191
psychology of 191–193
Health belief model 191–192, 191b
Health beliefs 167, 191
Health Canada
agencies of 45–48
Audit and Accountability Bureau 38
Biologic and Genetic Therapies Directorate 41
branches of 38–45
Cannabis Legalization and Regulation branch 45
Chief Financial Officer Branch 38
Communication and Public Affairs Branch 43
Corporate Services Branch 38–40
Departmental Secretariat 40
emergency powers 219–220
First Nations and Inuit Health Branch 40–41, 40–41b
global organizations collaborating with 48–54, 49b
Health Care Policy Directorate 43
Healthy Environments and Consumer Safety Branch 41
Healthy Products and Food Branch 41–43
Marketed Health Products Directorate 43–44, 44b
ministry level in 37–38, 38b
Natural and Nonprescription Health Products Directorate 42–43,
42–43b
objectives and responsibilities of 36–37
Office of Nursing Policy 43
Office of Nutrition Policy and Promotion 41–42, 42b
Opioid Response Branch 45
organizational structure of 38–45, 39f
Regions and Programs Branch 45
Special Access Program 103–104
Strategic Policy Branch 43–45
Therapeutic Products Directorate 42
Health card fraud 73
Health cards 72–73, 72–73b
Health care
allocation of resources in 266–269
ethical issues in 269–271
ethical theories in 248–250
evolution of 2–11
federal responsibility for 88–89
financial sustainability of 304–306
law and 207–244
mental
future of 285–286
and the Justice system 283–284
structure and implementation of services for 277–278
what's next for 288–289, 289b
regionalization of 61–67
relative cost of 289b
as a right 220–224
rights in 252–258, 253b
social media and 304–306
unions, legal implications 236–238
values in 247–248, 247–248b
Health care assistants 132
Health care a endants 132
Health care costs 86
of chronic diseases 89
drivers of 104
indirect costs 89–90
provincial/territorial costs 89, 89t
for technology 108
Health care delivery 86
Health care expenditures
for hospitals 90–99
by use of funds 91f
Health care facilities, independent 225–226, 225b
Health care funding 85–112
Canada Health Transfer 87
delivery vs. 86
distribution of 68, 68b
of hospitals 90–99
levels of 86–90
methods of 67–68
negotiating 88
priorities 267
private 86
public 88b
sources of 68
via premiums 68b, 85–86
Health care legislation
civil law 209
common (case) law 209
laws used in 208–212
constitutional law 208
regulatory law 208–209
statutory law 208
Health care organizations 144
Health care plans
funding of 67–68
portability of 71b
provincial and territorial 58–60
structure of 59–60
Health Care Policy Directorate, in Health Canada 43
Health care premiums 67, 68b
Health care providers
allied health professionals 114
categories of 114–117, 115t
complementary and alternative practitioners 114–117, 115t, 116b
conventional 114, 115t
ethical principles guiding 248–249
in hospital se ing 259
insured 78–79
mainstream 124–137
nonregulated 239
regulation of 117–124, 118–119t, 236
relationships with patients 258–259, 259b
Health care resources
allocation of 266–269
demand for 267–268
Health care spending 89
Health care strategies 22–23b
Health care teams 22–23
Health human resources (HHR)
cost of 104–108
defined 104
Health indicators 169
Health information
disposal of 232
ownership of 231–232
storage of 232
Health information management (HIM)
professionals
domains of practice of 135–136
training of 135–136
standards 135–136
Health insurance
introduction of 11–14
national, first a empts to introduce 11–12
political landscape in 12
prepaid hospital care in 12–13
prepaid medical care in 13–14, 14b
private 69
provincial 69–73
and territorial 58–60
third-party 69
types of 69–80
Health models 187–189, 188b
Health office administration 136
Health outcomes, accountability for 172
Health planning, public engagement in 172
Health prerequisites 154–155
Health professionals involved in MAID 223
Health promotion 152
Health records 230–236
ownership of 231–232
security of 234–235, 235b
Health Regulations, International 220
Health service organizations (HSOs) 143
Health services
as determinant of health 165–166, 166b
insured/uninsured 73–74
Health-illness continuum 193–199, 195f, 195b
Healthy child development, as determinant of health 164, 164–165b
Healthy Environments and Consumer Safety Branch (HECSB), in
Health Canada 41
Healthy Products and Food Branch, in Health Canada 41–43
HECSB See Healthy Environments and Consumer Safety Branch
HHR See Health human resources
HIM See Health information management
Hippocratic Oath 234b, 255b
Holistic model 181b, 187–188
Home care 21, 100, 137–139, 138b, 290–291, 290b
accessing 290–291
defined 79
future for 291, 291b
problems with 290
recipients of 290
p
in Saskatchewan 138–139, 139b
Home care support workers 132
Homelessness
mental illness and 281–284
reducing 282–283
Hospices 79, 113
Hospital administration, cost of 94
Hospital care
cost of 93–94, 93b, 95t
cost-reduction strategies 96–99
Hospital funding
activity-based funding 93
block funding 92
capitated funding 93
case-mix approach 93
line-by-line funding 92
mechanisms for 91–96
population-based funding 93
requirements for 93
service-based funding 93
Hospital Insurance and Diagnostic Services Act 12–13
Hospitalists 125
Hospitals
advantages of computerization in 300–301
bed management 97
cost of services 94–96
day surgery in 96b, 97
deliveries 97
development of, in Canada 7–8, 7b
expenditures for 90–99, 91f
insured services 75–76
integration of services 98–99
length of stay in 96
mergers of 98–99
palliative care in 98
private rooms in 96, 96b
rationalization of services 98–99
same-day admissions 96–97
timely discharge from 97
HSOs See Health service organizations
I
ICF See International Classification of Functioning Disability and
Health (ICF)
IFHP See Interim Federal Health Program
Illness
defined 185
stages of 197–198, 198b
Immigration and Refugee Protection Act 69
Immunization 267
Implied consent 228
Incident reports 212–213b
India Act (1876) 5
Indian tuberculosis 8
Indigenous Canadians, healing practices of, history of 3–6
contact with outsiders 5–6, 6b
Indigenous health care 293–299
access to service 295–296
care partners for 294–295
challenges of 294
demographics of 293–294
determinants of 294
health care providers and 296
practitioner retention for 296
related organizations for 296–297, 297b
specific issues of 294–296
Indigenous Medicine Wheel 188f
Indigenous people 199
segregated hospitals for 8
Indigenous wholistic theory, for health 188–189
Indirect capitation funding 106
Inequities in health 153
Infant mortality
calculating 200b
rate of 199
Influenza 52–54
Information technology, and electronic health records 299–304
Informed consent
defined 226
treatment to 226–230
Insured health care providers 78–79
Insured services
Canada Health Act and 73
hospitals 75–76
medically necessary procedures 76–77
vs. uninsured services 77b
Intellectual wellness 183–184
Intentional tort 210
Interim Federal Health Program (IFHP) 2–3, 36
International Classification of Functioning Disability and Health
(ICF) 189
International Health Regulations 220
Internists 125
Interprofessional collaboration 113–114
Intersectoral cooperation 171
Intubate 134
Involuntary confinement 238
Involuntary euthanasia 261, 262b
J
Jurisdiction 208
Jurisdictional framework 213–220, 213b
Justice 252
Justice system, mental illness and 283–284
K
Kelowna Accord, 2006 28
Kirby Report 24–26b, 156–157
L
Laboratory and diagnostic services 136
Lalonde, Marc 153
Lalonde Report, 1974 153
Laparoscopic surgery 97
Latimer, Robert 262b
Law
health care 207–244
health care professionals and 236–239
LEAN 304
Lean strategy 87
Legal problems, avoiding 212–213b
Legislation
defined 208
in health care 208–212
privacy 231
Lesbian 166
Levels of care 61b, 265
Liability insurance 239
Licensed practical nurses (LPNs) 130
Life expectancy 199, 200t
Limited use list (LU) 81b
Line-by-line funding 92
Literacy, as determinant of health 160–161, 161b
Litigation, duty of care and 211
Living will 261, 262b, 264–265
Long-term care accommodation, services offered by 79
Long-term care facilities
copayment for 101
funding of 100–102, 101–102b
provincial/territorial management of 101
quality of 102
LPNs See Licensed practical nurses
M
Magnetic resonance imaging (MRI) 108
MAID See Medical Assistance in Dying
Mainstream medicine 114
Malpractice 210
Marijuana
medical 217–219, 218b
recreational 218b
Marketed Health Products Directorate (MHPD), in Health
Canada 43–44, 44b
“Mature minors” 223
Mazankowski Report 24–26b
MedEffect 43–45
Medical Assistance in Dying (MAID) 222–224
Medical care, origins, in Canada 3
Medical Care Act 15–16, 15b
Medical Care Insurance Act 13–14
Medical marijuana 217–219, 218b
Medical model 187
Medical products, funding of 80
Medically necessary 20, 220–221
procedures
Canada Health Act on 74, 76–77
defined 224
prohibition on private insurance for 221–222
rare conditions and 268b
Medicare 13, 58
Medicine wheel 4–5
Meditation and wellness 184–185
Mental competence, and rights, in health care 257–258
Mental health, addiction and 277–286
Mental Health Act 238
Mental health care
future of 285–286
and the Justice system 283–284
structure and implementation of services for 277–278
what's next for 288–289, 289b
Mental health clinics 139–140
Mental Health Commission of Canada (MHCC) 28–29, 29b, 279
Mental health practitioners 278–279
Mental illness 277
challenges of 183
employment and 284–285, 285b
homelessness and 281–284
stigma of 279–280, 280b
Mental wellness 183
Methadone clinics 140–141
MHCC See Mental Health Commission of Canada
MHPD See Marketed Health Products Directorate
Midwives 130–131
Minister of health, responsibilities of 59
Ministry, in Health Canada 37–38, 38b
Minors
age of consent for 229
mature 223
Mobility 23–24
Morality 246–247
Morals 246–247
Morbidity 180
Mortality 180
Most responsible physician (MRP) 105
MRI See Magnetic resonance imaging
MRP See Most responsible physician
Municipal and Medical Hospital Services Act 13
N
Narrative charting 231
National Council Licensure Examination (NCLEX-RN) 127
National Council of State Boards of Nursing (NCSBN) 127
National Health Grants Program 12
National health insurance, first a empts to 11–12
Natural and Nonprescription Health Products Directorate, in Health
Canada 42–43, 42–43b
NCSBN See National Council of State Boards of Nursing
Negligence 210–211
Neurologists 125
Non-Insured Health Benefits (NIHB) Program 40
Nonmaleficence 250–251
Nonprofit organizations (NPOs) 98
Nonregulated health care providers 118–119t, 123–124, 123b, 239
Northern regions
health care plans in 65–66
primary care in 146–147
NPOs See Nonprofit organizations
NPs See Nurse practitioners
Nurse practitioner-led clinics 141
Nurse practitioners (NPs) 11, 127, 128b
Nurses
regulation of 117
shortage of 104
training of 127–129
Nursing, in early health care 10–11
Nursing homes, 274b-276b 100–102
Nursing services, cost of 96
O
Obstetricians and Gynecologists (OB/GYNs) 125
Occupational health and safety 214
legislation 214
and workers compensation boards 214–215
Occupational therapists (OTs) 134–135
Occupational therapy assistants (OTAs) 135
Occupational wellness 184
OECD See Organisation for Economic Co-operation and
Development
Office of Nursing Policy, in Health Canada 43
Office of Nutrition Policy and Promotion, in Health Canada 41–42,
42b
Oncologists 125–126
Ophthalmologists 125
Opioid crisis 215–216
Opioid Response branch, in Health Canada 45
Opticians 131
Optional services 21
Optometrists 131
Oral consent 228
Order of St. John 8
Organ transplantation 266–267, 267b
Organisation for Economic Co-operation and Development
(OECD) 51–54
Organizations, for indigenous health care 296–297, 297b
Orthodox 114
Osteopathic physicians 131
OTAs See Occupational therapy assistants
OTs See Occupational therapists
O awa Charter for Health Promotion, 1986 154–155, 154–155b
Outbreak 51
of influenza 52–53
Outpatient clinics 98, 139
Outsourcing 109
P
PAHO See Pan-American Health Organization
Palliative care 266
community-based 98
provincial/territorial services in 79
Pan-American Health Organization (PAHO) 50–51
Pandemic 51
Parental rights 257
ParticipACTION 190–191
PAs See Physician assistants
Passive euthanasia 261, 262b
Patent Act 103
Patented drugs 47
controlling the cost of 103–104
Patented Medicine Prices Review Board (PMPRB) 47, 103–104
Paternalism 255, 255–256b
Patient a achment 145
Patient focus, clinics and 141
Patient service associates 132
Patients' bill of rights 254
Patient's Medical Home (PMH) 113–114
Payroll tax 67–68
Personal health practices, as determinant of health 163–164, 163–164b
Personal Information Protection and Electronic Documents Act, 2004
(PIPEDA) 232–234
Personal support workers (PSWs) 11, 132–133, 132–133b
PET scanners 108
PHAC See Public Health Agency of Canada
Pharmacists 130
Physiatrists 126
Physical environment, as determinants of health 163
Physical wellness 183
Physician assistants (PAs) 129
y
Physician-assisted suicide 261, 261b
Physician-patient relationship, termination of 238
Physicians 104, 105b
blended funding of 106
capitation-based funding of 106
fee-for-service (FFS) funding of 105
global budget funding of 106
indirect capitation funding of 106
most responsible physician (MRP) 105
payment methods 105
salary for 106
specialists compensation 107
training of 124–126
Physiotherapists 134
Physiotherapy assistants (PTAs) 135
PMH See Patient's Medical Home
PMPRB See Patented Medicine Prices Review Board
Podiatrists 131–132
Political landscape 12
Poor health, cost of 89–90
Population-based funding 93, 106
Population-based surveillance 170b
Population health 151–153, 152–153b
approach 168–172, 168b
actions sectors and levels, collaborate 171–172
determinants of health and their interactions 169–170, 169f
evidence-informed decision making, use 170
health outcomes, demonstrate accountability for 172
multiple strategies, apply 171
public, engage 172
target, focus on 169, 170b
upstream investments, increase 170–171
in Canada 151–178
abroad and 173–174
introduction of 153–157
Population health promotion model 172–173
Portability 18, 19b
Power, balance of, in therapeutic relationship 259–260
Power of a orney 229
Practice se ings 113, 137–141
Practitioners and workplace se ings 113–150
Premature deliveries 270
Prepaid hospital care 12–13
Prepaid medical care, progress toward 13–14, 14b
Prescribing medical cannabis 218
Prescription drugs, advertising 219
Primary care
access to 60f, 165–166
defined 59
vs. primary health care 59
Primary care physicians 124
Primary care renewal, goals of 23t
Primary care se ings 113
Primary health care 153, 154b
beginnings of 142–147
declaration of Alma-ata and 312
ongoing shortage 142–143
strategies for improvement 142–143
vs. primary care 59
Primary health care groups
examples of 143–146
forming 143
patient enrollment in (rostering) 145–146, 145b
payment mechanisms for 145
regional variations of 143–145
structure and function of 143
Primary health care reform 22–23, 23t
funding of 106
groups 145–146, 146b
Privacy 135–136
Privacy Act (1983) 233
Privacy laws 232–234
Privacy legislation 231
Private clinics
concerns about 75b
examples of 224
government funding of 226
legality of 74
Private health care
access to 221–222, 226
existence of 74–75
legislation covering 224
Private health insurance 69
Private law 209–212
Private residences, continuing care in 100
Private services, legality of, in Canada 224–226, 225b
Procedural justice 252
Professional misconduct 210
Protection motivation theory 193, 194b
Provincial and territorial governments, role of 217–219
Provincial insurance plans 69–73 See also Provincial/territorial health
care plans
applying for 69–72, 70–72b
eligibility for 69
portability of 71b
reciprocal agreement 71b
Provincial/territorial drug benefits 80, 82b
Provincial/territorial governments
role in health care 57–84, 57–58b
structure of health care systems 59–60
Provincial/territorial health care plans 57–84 See also Provincial
insurance plans
Alberta 62–63
British Columbia 62
categories of care 59
funding of 67–68
Manitoba 63
New Brunswick 65
Newfoundland and Labrador 65
northern regions 65–66
Northwest Territories 66
Nova Scotia 65
Nunavut 66–67
Ontario 63–64
Prince Edward Island 65
Quebec 64
regionalization initiatives 61–67
Saskatchewan 63
Yukon 66
PSWs See Personal support workers
Psychiatrists 126
Psychologists 133
PTAs See Physiotherapy assistants
Public health 152, 152b
concept of 10
Public Health Agency of Canada (PHAC) 47–48, 48b
g y
template 168–169, 169f
Public Health Program Initiative 155, 155–156b
Public health units 10
Public law 209–212
Public Safety Canada 50
Publicly funded health care 85–86, 88b, 208
Publicly funded health care system 12
Pulmonologist 126
Q
Qualitative research 170
Quantitative research 170
Quarantine 2
Quarantine Act 219
Queer 166
Questioning 166
R
Radiologists 126
Rationalization of services 91
Reasonable access 18–19
Reciprocal agreement 71b
Recreational cannabis, legalization of 217
Refraction 125
Refugee claimants 36–37
defined 88–89
health care for 88–89
health insurance for 2–3
Regional health authorities (RHAs) 60, 61b
Regionalization 61–67
Regions and Programs Branch, in Health Canada 45
Registered nurses 11
practice se ings of 95
regulation of 117
training of 127
Registered practical nurses (RPNs) 128–129
Registered psychiatric nurses (RPNs) 128–129, 278
Regulated health care providers
codes of ethics for 236
common elements among 120b
complaint processes for 122, 236
educational standards for 122
licensing of 123, 123b
provincial/territorial differences between 118–119t
Regulated Health Professions Act (RHPA) 120
Regulations 208–209
Regulatory law 208–209
Religion, influence on health beliefs 192
Remission 185, 185b
Renal dialysis 96
Report on the Health of Canadians 155–156, 157b
Reserved acts 120
Resident care aides 132
Residential care 100
Residential schools 6b
Respect 251
Respiratory therapists (RTs) 134
Respirologists 126
Respite care 79
Restraints, legal issues around use of 239
RHA See Regulated Health Professions Act
RHAs See Regional health authorities
Right to die 263
Rights in health care
controversies around 252–253
defined 253b
duties and 254
mental competence and 257–258
parental rights 257
Risks of information, from social media 306
RN See Registered Nurses
Role fidelity 251–252, 252b
Romanow Report 24–26b, 156–157
impact of 26–27, 27b
Rostering 145–146, 145–146b
RPNs See Registered psychiatric nurses
RTs See Respiratory therapists
Rural Municipality Act 11
S
Safe consumption site 281
Saskatchewan, home care in 138–139, 139b
Saskatchewan Medical Care (Insurance) Act 14b
Scope of practice 120b
Secondary care
access to 60f
defined 59
Self-determination 247
Self-discharge from hospital 239
Self-imposed risk behaviours 163, 189, 191b, 199, 200t
SEM See Social-ecological model
Sense of duty 248, 248b
Service-based funding 92
Shamans 6–7
Sick building syndrome 163
Sick role behaviour
defined 195–197, 196b
in hospital 197b
Signs (of illness) 197–199, 198b
Smallpox vaccinations 10
Smudging 4
Social-ecological model (SEM) 193
Social environment, as determinants of health 162–163, 162b
Social media 305
health care and 304–306
Social movements 12
Social status, as determinant of health 157–158, 158–159b
Social support networks, as determinant of health 159–160, 160b
Social union 23–24
Social wellness 184
Socioeconomic gradient (SES gradient) 155, 156b
SPB See Strategic Policy Branch
Specialists
compensation for 107
training of 124
Speech-language pathologists 133
Spiritual ceremonies, in Indigenous Canadians 4
Spiritual wellness 184, 184b
St. John Ambulance See Order of St. John
St. John’s International See Order of St. John
Staffing shortages 22
Stages of illness 197–198, 198b
Statutory law 208
Strategic Policy Branch (SPB), in Health Canada 43–45
Support groups 305–306
Surgeons 126, 126b
Sweat lodge 4
Symptoms (of illness) 197–199, 198b
T
Tax credits, for caregivers 98
Tax points 15b
Telehealth 146
Teleological theory 249
Telephone helplines 146, 146–147b
Territorial Formula Financing (TFF) 87–88
Tertiary care
access to 60f
defined 60
TFF See Territorial Formula Financing
The Canadian Indigenous Nurses Association (CINA) 296
Therapeutic Products Directorate, in Health Canada 42
Therapeutic relationship
balance of power in 259–260
transference in 259–260
trust in 259
vulnerability in 259
Third-party health insurance 69, 76–78
Tight building syndrome 163
Title protection 117–120, 120b
Tort law 210–211, 211b
Traditional medicine 114
Traditional rituals, in Indigenous Canadians 4
Transference, in therapeutic relationship 259–260
Transgender (or trans) 166
Transsexual 166
Transtheoretical model 193
Trust, in therapeutic relationship 259
Truthfulness 251, 256, 256b
Tuberculosis sanitariums 7
2014 Health Accord 29
2017 Health Accord 30
Two Spirit 166
Two-tier system 75b
U
Unemployment insurance program 11–12
Uninsured services
block payment plan for 77b
Canada Health Act and 73
plans 76–78
vs. insured services 77b
Unintentional tort 210
United Nations (UN), with Health Canada 48
Universality 17–18, 18b
Upstream investments 171
Urgent care clinics 139
Urodynamic 139
User charges 21
V
Vaccinations 10, 90b
Vaccines, ethical use of 54b
Values, in health care 247–248, 247–248b
Values history form 265, 265b
Victorian Order of Nurses 9, 9b
Virtue ethics 249–250, 249b
Voluntary consent 227
Voluntary euthanasia 261, 261–262b
Volunteer caregivers 137
Volunteer organizations, in early health care 8–10
Volunteerism, as determinant of health 162
VON See Victorian Order of Nurses
Vulnerability, in therapeutic relationship 259
W
Wait times, reasonable wait times 254
Walk-in clinics 139
WCB See Workers Compensation Board
Wellness
defined 180
dimensions of 182–185, 182f
emotional 183
environmental 184
intellectual 183–184
key concepts of 181–185
occupational 184
physical 183
social 184
spiritual 184, 184b
Wellness-illness continuum 193–194
Wellness model 189
Western medicine 114
Whistleblowers 240
WHMIS See Workplace Hazardous Materials Information System
WHO See World Health Organization
Workers Compensation Board (WCB) 214
Working conditions, as determinant of health 161–162
Workplace Hazardous Materials Information System (WHMIS) 214–
215
Workplace Health and Public Safety Program 45
Workplace safety 214–215
World Health Assembly 50
World Health Organization (WHO) 50
Alma-Ata Conference 153
on concept of health 181, 181b
p
with Health Canada 48–49
International Classification of Functioning Disability and Health
(ICF) 189
International Health Regulations 219
six-point agenda 49b
Wri en consent 227–228
Z
Zika syndrome, congenital 52
Zika virus 52