5. Provision of services
lthough it is difficult to generalize given the decentralized nature of health services administration and delivery in Canada, the typical patient pathway starts with a visit to a family physician, who then determines the course of basic treatment, if any. Family physicians act as gatekeepers: they decide whether their patients should obtain diagnostic tests, prescription drug therapies or be referred to medical specialists. However, provincial ministries of health have renewed efforts to reform primary care in the last decade. Many of these reform efforts focus on moving from the traditional physician-only practice to interprofessional primary care teams that provide a broader range of primary health care services on a 24-hour, 7-day-a-week basis. In cases where the patient does not have a regular family physician or needs help after regular clinic hours, the first point of contact may be a walk-in medical clinic or a hospital emergency department.
Illness prevention services including disease screening may be provided by a family physician, a public health office or within a dedicated screening programme. All provincial and territorial governments have public health and health promotion initiatives. They also conduct health surveillance and manage epidemic response. While PHAC develops and manages programmes supporting public health throughout Canada, most day-to-day public health activities and supporting infrastructure remains with the provincial and territorial governments.
Almost all acute care is provided in public or non-profit-making private hospitals in Canada, although some specialized ambulatory and advanced diagnostic services may be provided in private profit-making clinics. Most hospitals have an emergency department that is fed by independent emergency medical service units providing first response care to patients while being transported to emergency departments.
As for prescription drugs, every provincial and territorial government has a prescription drug plan that covers outpatient prescription drugs for designated populations (e.g. seniors and social assistance recipients), with the federal government providing drug coverage for eligible First Nations and Inuit. These public insurers depend heavily on HTA, including the CDR conducted by the CADTH, to determine which drugs should be included in their respective formularies. Despite the creation of a National Pharmaceuticals Strategy following the 10-Year Plan agreed by first ministers in 2004, there has been little progress on a pan-Canadian catastrophic drug coverage programme.
Rehabilitation and long-term care policies and services, including home and community care, palliative care and support for informal carers, vary considerably among provinces and territories. Until the 1960s, the locus of most mental health care was in large, provincially run psychiatric hospitals. Since deinstitutionalization, individuals with mental illnesses are diagnosed and treated by psychiatrists on an outpatient basis even though they may spend periods of time in the psychiatric wards of hospitals. Family physicians provide the majority of primary mental health care.
Unlike mental health care, almost all dental care is privately funded in Canada. As a consequence of access being largely based on income, outcomes are highly inequitable. CAM is also privately funded and delivered.
Due to the disparities in health outcomes for Aboriginal peoples – as well as the historical challenge of servicing some of the most remote communities in Canada – F/P/T governments have established a number of targeted programmes and services. While Aboriginal health status has improved in the post-war period, a large gap in health status continues to separate the Aboriginal population from most other Canadians.
5.1 Public health
Public health aims to improve health, prolong life and improve the quality of life through health promotion, disease prevention and other forms of health intervention. Unlike the other services covered in this chapter, the majority of public health policies and programmes target populations rather than individuals. Provincial governments have had a long history of public health interventions dating back to 1882 when Ontario’s Public Health Act established a broad range of public health measures, a permanent board of health and the country’s first medical officer of health.
In Canada, public health is generally identified with the following six discrete functions: population health assessment, health promotion, disease and injury control and prevention, health protection, surveillance and emergency preparedness and epidemic response. The F/P/T governments (and their delegated authorities including RHAs) perform some or all of these functions. All governments appoint a chief public or medical health officer to lead their public health efforts in their respective jurisdictions. These individuals are generally physicians with specialized education and training in public health.
By virtue of their extensive responsibilities for health and health care, provincial ministries of health all have public health branches (some even have a separate public health agency or department) with responsibility for the six discrete functions of public health. In addition, most ministries of health have launched major population health initiatives in recent years. In some provinces, RHAs have initiated their own public health promotion and illness prevention programmes in areas of greatest need for their respective populations.
The federal government also provides a broad range of public health services principally through PHAC, which coordinates, at least in part, the six public health functions described above. PHAC is responsible for disease surveillance including reporting back to WHO and other relevant international bodies. PHAC also administers a network of disease-control laboratory services such as the National Microbiology Laboratory. Like Health Canada, PHAC is responsible for funding and administering a number of public health programmes, some of which emphasize the social determinants of health, including the Aboriginal Head Start Program, the Canada Prenatal Nutrition Program and the Healthy Living Strategy, and illness prevention programmes for AIDS and tobacco reduction.
The CPHA is a voluntary organization dedicated to improving the state of public health in Canada. In conjunction with its provincial and territorial branches or associations, CPHA advocates for greater awareness of the impact of public health interventions and encourages public health research and education.
The provinces are mainly responsible for the funding and administration of screening programmes for the early detection of cancer, and all provincial and territorial ministries of health have implemented one or more of these programmes. Although they vary considerably in approach, delivery and comprehensiveness, provincial governments do adopt screening programmes developed in other provinces once they have proven successful. For example, British Columbia was the first province to initiate a population-based breast cancer programme in 1988. Two years later, the province of Ontario began to provide population-based breast cancer screening for women aged 50 or older. Following this, the Canadian Breast Cancer Screening Initiative was launched with funding support from Health Canada, and a pan-Canadian breast screening surveillance database was established based on provincial data. Organized breast cancer screening is now the norm rather than the exception in Canada (Cancer Care Ontario, 2010; PHAC, 2011). It is estimated that screening contributed to roughly half of the reduction in breast cancer mortality in Canada between 1986 and 2005 (Wadden, 2005). Cervical cancer screening and surveillance followed a very similar trajectory in the 1990s.
In the 2000s, there has been a major effort to improve and extend screening for colorectal cancer, the second leading cause of cancer mortality in Canada. By 2004, clinical guidelines had been established for colorectal cancer testing. In 2007, based on the success of an earlier pilot project, the government of Ontario established a province-wide, population-based colorectal cancer screening programme, the same year that the Government of Manitoba set up its own organized screening pilot project. One year later, a large sample of Canadians was asked if they had received the recommended colorectal cancer testing to determine the impact of population-based as opposed to physician-based screening (Table5.1). Although self-reported results must be treated cautiously, they did indicate substantially higher levels of screening in Ontario and Manitoba and will most likely encourage other provinces to institute population-based screening for colorectal cancer.
All provincial and territorial ministries of health also devote resources to communicable and infectious disease control. However, given the geographical reach of such diseases and the rapidity with which they spread, the federal government has begun to play a larger role in both control and surveillance. The SARS (severe acute respiratory syndrome) outbreak in 2003 and the advisory report that followed in its wake were the catalysts for a policy change, which many public health advocates considered overdue (Health Canada, 2003). One year later, PHAC was established with a mandate to monitor, prepare for and respond to disease outbreaks in addition to other public health functions.
Immunization planning and programming is also a primary responsibility for provincial and territorial health ministries (De Wals, 2011). Immunization can be delivered in a number of ways but the two most common are through family physicians or regionally based public health offices. The National Advisory Committee on Immunizations is a pan-Canadian committee of recognized experts that works with, and reports the results of its deliberations to PHAC. Its recommendations are conveyed to the public, including health providers and health system decision-makers, in the Canadian Immunization Guide, which is published every five years (NACI, 2006).