240. CCA Study Notes: Canada’s Health Care System, Indigenous Health, and Care Delivery

The Big Picture

Canada has a publicly funded health care system. The federal, provincial, and territorial governments share responsibility for different parts of that system.

Each province and territory develops its own health care policies. This means health care does not work exactly the same way everywhere in Canada.

This Topic also covers Indigenous health, the different levels of health care delivery, and the growing role of home care.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

How Canada’s Health Care System Is Organized

Canada’s publicly funded system consists of connected health insurance plans shared by the federal government, 10 provinces, and 3 territories.

Provincial and territorial governments fund and deliver health services with financial help from the federal government.

Medicare is Canada’s national health care insurance system. It publicly funds medically necessary health services for permanent residents.

Medically necessary hospital and physician services are provided without payment at the time the service is delivered.

Each province and territory develops its own health care policies. As a result, some policies differ across Canada.

The Five Principles of the Canada Health Act

The Canada Health Act (1984) sets five principles that provincial and territorial medicare plans must meet to receive their full share of federal health care funding.

1. Comprehensiveness

Comprehensiveness means the insurance plan covers medically necessary services.

Necessary hospital drugs, supplies, and diagnostic tests are covered. A range of medically necessary services provided outside hospitals is also covered.

2. Universality

Universality means permanent residents are entitled to insured health care services on similar terms and conditions.

3. Portability

Portability means health coverage continues when a person becomes unemployed, changes jobs, travels, or moves.

A person who moves to another province or territory must inform the previous jurisdiction and register with the new one.

During the transition, the previous jurisdiction provides coverage for up to 3 months.

4. Accessibility

Accessibility means people receive medically necessary services regardless of income, age, health status, gender, or geographic location.

Additional charges for publicly insured services are not permitted.

5. Public Administration

Public administration means the health insurance plan operates through a public organization on a nonprofit ⓘ basis.

That organization remains accountable ⓘ to citizens and the provincial or territorial government.

How Medicare Developed

Health care in Canada looked much different during the early twentieth century.

People generally paid their own physician and hospital bills. Fees were not always fixed, and some people depended on charitable organizations for care.

Others went without medical care because they lacked enough money.

During the Great Depression of the 1930s, many families struggled to pay for food, clothing, housing, and medical care. Serious illness or hospitalization placed a major financial burden on families.

These hardships helped create support for prepaid medical and hospital insurance.

In 1947, Saskatchewan became the first province to introduce a public insurance plan covering hospital services. Premier Tommy Douglas led the province at that time.

By 1972, every province and territory had extended insurance coverage to medical services provided outside hospitals. Modern medicare began that year.

Tommy Douglas and the Development of Medicare

Thomas Clement Douglas lived from 1904 to 1986. His reforms in Saskatchewan helped shape Canadian social and health care policy and contributed to the development of medicare.

One health-related reform provided medical and hospital benefits to welfare recipients without out-of-pocket ⓘ payment at the time of care.

The Federal Government’s Role

The federal government has several responsibilities within Canadian health care.

These include:

• administering the Canada Health Act and providing funding to provinces
• directly delivering health services to certain groups
• developing programs and policies that promote health and prevent disease
• approving drugs
• assessing health risks from environmental hazards
• supporting public health programs
• transferring tax money to provinces and territories for medically necessary health services
• prohibiting extra charges and user fees for insured services
• ensuring that provinces and territories provide the same quality and type of care

Groups receiving direct federal health services include First Nations people living on reserves, Inuit peoples, serving members of the Canadian Forces and Royal Canadian Mounted Police, eligible veterans, and people in federal penitentiaries.

Public Health Is a Shared Responsibility

Public health services are generally delivered at provincial, territorial, and municipal ⓘ levels.

The federal Public Health Agency of Canada serves as a central organization for disease prevention and control. It also supports emergency responses to infectious disease outbreaks.

Indigenous Health Services in Canada

Responsibility for Indigenous health services is shared among federal, provincial, and territorial governments and Indigenous organizations.

Health Canada has worked with Indigenous organizations and communities on health promotion and the prevention of persistent and contagious diseases.

Some health outcomes have improved, including lifespan and infant survival.

Important health gaps still remain. Suicide, injury, and diabetes occur more often among First Nations, Métis, and Inuit peoples than the Canadian average.

Historical Barriers to Indigenous Health Care

Indigenous peoples have faced barriers to accessing health care across Canada.

These barriers have included:

• geography
• poor organization of services
• language differences
• cultural barriers
• socioeconomic conditions ⓘ

Access to universal health care developed slowly for many Indigenous communities.

Traditional Indigenous health practices were also often overlooked in favour of non-Indigenous medical approaches.

Changes in Indigenous Health Services Over Time

The federal role in Indigenous health services changed over many decades.

• 1945: Health services for Indigenous peoples were transferred from the Department of Indian Affairs to Health Canada.
• 1962: Health Canada’s Medical Services Branch began providing direct health services to First Nations people living on reserves and Inuit people in the North.
• 1974: A federal policy stated that Health Canada would ensure health services were available, even though the policy said no treaty required the government to provide health care.
• 1979: A new Indian Health Policy addressed uninsured benefits and emphasized community development and stronger relationships among First Nations people, the federal government, and the Canadian health system.
• Mid-1980s: Work began to give First Nations, Métis, and Inuit communities more control over their own health services.
• 1998: Gathering Strength: Canada’s Aboriginal Action Plan emphasized diabetes and tuberculosis initiatives, the Aboriginal Healing Foundation, and healing related to residential schools.
• 2000: The Medical Services Branch became the First Nations and Inuit Health Branch.

Residential Schools and Health

Government policies separated generations of Indigenous children from their families and placed them in residential schools.

Children were forced away from their Indigenous languages, beliefs, and practices.

These policies caused physical and mental harm across generations.

In 2015, the Truth and Reconciliation Commission of Canada identified seven Health Calls to Action aimed at addressing this legacy.

The Seven Health Calls to Action

The seven health-related Calls to Action are numbered 18 through 24.

1. Call 18: Acknowledge the connection between past Canadian government policies, including residential schools, and Indigenous health, and recognize Indigenous health-care rights.
2. Call 19: Set measurable goals, report progress, and track health differences between Indigenous and non-Indigenous communities.
3. Call 20: Recognize and address the distinct health needs of Métis, Inuit, and off-reserve Indigenous peoples.
4. Call 21: Provide sustainable funding for existing and new Indigenous healing centres.
5. Call 22: Recognize Indigenous healing practices and work with Indigenous healers and Elders when Indigenous patients request this.
6. Call 23: Increase Indigenous health professionals, support their retention in Indigenous communities, and provide cultural competency training.
7. Call 24: Require medical and nursing students to learn about Indigenous health, residential schools, Indigenous rights and teachings, intercultural competency, conflict resolution, human rights, and anti-racism.

Indigenous Healing and Wellness

Indigenous health and wellness uses a holistic model.

This approach focuses on balance and relationships among four parts of the person:

• physical
• mental
• emotional
• spiritual

Traditional healing includes Indigenous health practices, knowledge, approaches, and beliefs.

Traditional healing might involve ceremonies, medicines made from plants, animals, or minerals, energetic therapies, or physical and hands-on techniques.

Government strategies increasingly encourage health services that respect Indigenous cultures and include culturally sensitive approaches.

Primary, Secondary, and Tertiary Health Care

Every province and territory provides primary, secondary, and tertiary health care.

These levels differ in purpose and complexity.

Primary Health Care Delivery

Primary health care delivery is the first point of contact most people have with the health care system.

Contact might occur through:

• a doctor
• a nurse
• another health care provider
• telephone-based services
• computer-based services

Primary care usually takes place in the community, though it also occurs in hospitals.

It focuses mainly on:

• health promotion
• early diagnosis of disease or disability
• disease prevention

Primary health care teams include family doctors, nurses, nurse practitioners, and other health care providers.

The members of these teams vary according to community needs and provincial or territorial priorities.

Primary health care reforms have included more community health centres offering services throughout the day, teams that include family nurse practitioners, better coordination and integration of services, improved work environments, and greater emphasis on health promotion, illness and injury prevention, and management of persistent diseases.

Telehealth services provide health advice and after-hours access to primary care. Team-based primary care and telehealth also reduce the use of emergency care units.

Secondary Health Care Delivery

Secondary health care delivery deals with more complex medical issues.

It includes assessment, diagnosis, treatment, and preventive services.

Specialist physicians and other specialized health providers generally provide this level of care.

A family doctor or nurse practitioner might refer a person to a specialist for a medical issue requiring specialized diagnosis or treatment.

Secondary care takes place in community settings or hospitals.

Tertiary Health Care Delivery

Tertiary health care delivery is a highly specialized and technical level of care.

It takes place in large research and teaching hospitals.

Tertiary care often occurs in specialized units, such as critical care units.

It requires:

• advanced diagnostic support
• advanced treatment support
• highly specialized personnel

Tertiary care is the most expensive level of health care delivery.

Quaternary Care

Quaternary care is an even more specialized part of tertiary care.

It includes experimental medicines or surgical procedures.

Not every health care centre offers this level of service.

The Shift Toward Home Care

Canada’s health care system has gradually shifted some care away from hospitals and into people’s homes.

Hospitals cost large amounts of money to operate. More than one-third of health care spending goes toward hospitals.

Over time, many hospitals have closed, merged, or changed into other types of health care facilities.

People also leave hospital sooner after procedures than they did in the past.

Several factors contributed to this change:

• reducing costs
• advances in technology
• reducing infection rates

Government spending on home care has increased to support people after earlier hospital discharge.

What Home Care Means

Home care means health care and support services provided where a person lives.

This includes:

• private homes
• licensed live-in care facilities
• assisted-living facilities

Home care is the most common type of community-based service.

Support workers provide much of the support delivered through home care programs.

Who Receives Home Care?

Home care serves many groups.

Clients include:

• older persons
• families with children
• people with mental, physical, or developmental disabilities
• people with short-term medical conditions
• people with long-term medical conditions
• people recovering from illness
• people receiving rehabilitation
• people in the final stages of a life-ending disease

Home care also assists families with a new baby.

For some people, home care replaces hospital or facility care. For others, it supports health and independence and delays or prevents admission to a facility.

A major goal is helping people remain at home, stay as healthy as possible, and maintain independence for as long as possible.

Home Care Funding

Every province and territory has a publicly funded home care program.

Indigenous Services Canada also uses federal contribution agreements to fund health programs and services for First Nations people living on reserves and Inuit people in the North.

Public and private agencies provide support services. These organizations operate on either a for-profit or nonprofit basis.

Funding and services differ across provinces and territories because each jurisdiction defines and funds its own home care system.

Eligibility ⓘ and the number of service hours also vary.

People who want services that public programs do not fund, or who do not qualify for funded services, may purchase services from a private agency or through private insurance.

Services Offered Across Canada

All provinces and territories offer:

• client assessment to determine eligibility
• case coordination and management
• nursing services
• support services for eligible clients

Personal Care Services

Personal care services are nonmedical home care services often provided by support workers.

They include help with activities of daily living, or ADLs, such as:

• bathing
• feeding
• mobility
• dressing

Personal care also includes comfort care for clients who are dying.

Home Support Services

Home support services are often provided by support workers to clients living at home.

They include:

• help with home management
• help with ADLs
• help with taking medications

Professional Services

Professional services include therapies and treatments delivered by the appropriate health care providers.

Examples include:

• nursing care
• physiotherapy
• occupational therapy
• speech therapy
• nutrition counselling
• social work
• respiratory therapy
• paramedic and emergency medical technician services
• nail care
• in-home blood testing

Support for Instrumental Activities of Daily Living

Instrumental activities of daily living, or IADLs, involve tasks that support independent living.

Support workers often assist with these activities.

Examples include:

• shopping with a client
• helping a client with banking
• teaching a client how to follow a recipe

Volunteer Services

Volunteer services also support people living in the community.

Examples include Meals on Wheels and friendly visiting.

These services are provided by people who meet the volunteer requirements.