The health emergency resulting from the spread of Covid-19 did not spare Canada. Like other countries in the world, the public health system is under pressure. However, it was able to draw on a painful lesson: the one learned with SARS in 2003.

 

In this study of the Centro Studi Italia Canada, we delve into the salient features of Canadian Medicare, the trends in healthcare spending, the measures adopted against the spread of Coronavirus and the Canada's Covid-19 vaccine distribution implementation plan.

 

Nadia Deisori*

 

Canada has a publicly funded healthcare system. Commonly called Medicare, Assurance-maladie in French, public health insurance is financed by all Canadians through the progressive tax system.

 

Thanks to a lifestyle among the best in the world and a relatively young population, the health system in Canada has some strengths. The universalistic principle, for example, which guarantees all residents of Canada top-level health care and health policies generally oriented towards information and prevention plans and actions.

 

However, some weaknesses remain, exacerbated by the progressive decentralization of health governance from the central to the local level. These include the heterogeneity of health performances between the different Provinces / Territories and between urban-rural areas within the same Provinces.

 

Federal policies and local governance

In fact, the Canadian health system consists of 13 different provincial and territorial health plans, which are entrusted with the provision and organization of health services according to principles established by the Federal Government.

The roles and responsibilities for the health system are shared, that is, between the federal, provincial and territorial governments.

 

1. Provincial and territorial governments have primary jurisdiction in the administration and delivery of health care, including setting priorities, administering budgets and managing resources

 

2. The federal government, in addition to providing health data, research and regulatory infrastructure, defines the national principles that must inspire provincial and territorial health insurance plans.

The federal government also directly administers a range of health services including those for First Nations living in reserves, the Inuit, and members of the armed forces and the Royal Canadian Mounted Police, veterans and detainees of federal penitentiaries.

 

 

The Canada Health Act

 

The primary objective of Canadian health care policy is to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers

 

The Canada Health Act, adopted in 1984, specifies the conditions and criteria that provincial and territorial health plans must comply with in order to receive federal transfers under the Canada Health Transfer.

 

The law only deals with how the system is funded. That is, it does not concern the methods in which care is organized and provided, which is left to the provincial / territorial jurisdiction, provided that the fundamental criteria and principles expressed in the law are respected.

 

In the 2018-2019 fiscal year, the federal health system transferred approximately $ 38.6 billion to the provinces and territories of Canada.

 

What are the health services guaranteed in Canada?

 

The law specifies that the guaranteed services include three categories of services.

 

1. Hospital services

Insured hospital services for all Canadian citizens are:

• the hospitalization services necessary from a medical point of view, such as accommodation and meals
• the nursing service
• laboratory, radiological and other diagnostic procedures, together with the necessary interpretations
• drugs, biological substances and related preparations administered in hospital
• the use of the operating room, the clinical room and anesthetic structures, including the necessary equipment and supplies
• medical and surgical equipment and supplies
• the use of radiotherapy facilities
• the use of physiotherapy facilities
• other services provided by people who receive remuneration from the hospital

 

2. Insured medical services

Those services requested by the doctor are guaranteed, generally determined by the provincial or territorial health insurance plan, in consultation with the medical profession.

 

3. Surgical-dental services

Dental care that requires a hospital environment for the proper execution of procedures.

 

Extended health services

Then there are the extended health care services, which include some aspects of long-term residential care (intermediate level home nursing and residential adult care services) and the health aspects of home care and home care services. Outpatient care. Within the limits of the Federal Government, established in specific Regulations, Provinces / Territories also provide these additional services in their respective health plans.

 

 

What are the principles established by the federal government?

 

The Canada Health Act contains 5 criteria and 2 conditions that provinces and territories must meet in order to qualify for the full amount of healthcare expenditure incurred.

 

1. Universality

It is the most important principle that characterizes Canadian health because it establishes the right of all insured residents, regardless of the Province or Territory of residence, to access the same conditions to the insured health care services provided by the provincial or territorial health insurance plan.

 

2. Public administration

Provincial and territorial health insurance plans must be managed by a public authority. This does not prevent that external intervention may be requested for some services necessary for the administration, such as the processing of payments to doctors. In addition, private facilities can provide insured health care services as long as there are no charges for the assisted person.

 

3. Completeness

The health insurance plans of Provinces and Territories must cover all insured health care services.

 

4. Portability

This principle means that no one is left "not covered" by health care during a transfer of residence. Moving residents must continue to be covered for health care services guaranteed by the jurisdiction of origin during any waiting period (up to three months) imposed by the new Province or Territory of residence before coverage is established in the new jurisdiction.

 

5. Accessibility

In other words, the Federal Government asks to ensure that insured persons in a province or territory have reasonable access to insured health services on uniform terms and conditions, which are not precluded or not prevented by extra charges and billing to the user or other causes ( for example, discrimination based on age, health or economic conditions).

 

Source: Government of Canada

 

This principle has been interpreted with the "where and how" rule. That is, the residents of a Province or Territory have the right to have access, under uniform conditions and terms, to the health care services insured in the place where "the services are provided" and "how" the services are available in that context. The example given is that of a hospital that offers a given highly specialized service in a certain Province. All other hospitals in the province are not obliged to provide similar services, but all residents have the right to access that service.

 

In addition, provincial and territorial health insurance plans must include:

 

• reasonable compensation for doctors and dentists for all insured health care services they provide
• payment to hospitals to cover the costs of insured health services.

 

The conditions

 

The 2 additional conditions to be able to access the transfers of the Federal Government that the local plans must respect are:

 

1. Information

Provincial and territorial governments are required to provide information to the Federal Minister of Health for the preparation of annual reports, presented to Parliament, on how the Province has administered its health care services in the previous year.

 

2. Recognition

Provincial and territorial governments are required to recognize federal financial contributions to both insured and extended health care services in all public documents or in any advertising or promotional material relating to health services insured in the Province.

 

 

Healthcare spending in Canada

 

About 70% of Canadian healthcare expenditure is paid out of public resources. According to the Canadian Institute for Health Information, healthcare spending grew 3.9% in 2019, reaching $ 264.4 billion (11.6% of Canadian GDP).

 

The largest share of healthcare expenditure is represented by hospitals, doctors, and drugs but with varying trends over the past few decades.

 

Source: National Health Expenditure Database, Canadian Institute for Health Information

 

Hospitals are public facilities in Canada. In the 1980s, hospital spending grew at a faster rate, driven by the share of personnel costs and generally higher remuneration.

 

With expenditure restraint in the 1990s and early 2000s, hospital funding slowed down and the share of growth in public spending slowed.

 

The response to this financial change has been a shift in many treatments from hospitalized therapies to outpatient care.

 

The reduction in the number of hospital beds per capita, from 3 in 2006 to 2.5 in 2018, is a decrease that the OECD has recorded in almost all countries since 2000 as an effect of advances in medical technology but also a political strategy to reduce hospitalizations.

 

Source: OECD Health Statistics: Health care resources

 

Healthcare spending in the private sector has remained relatively sizeable over the past twenty years and makes up the remaining 30% of Canada's total healthcare spending.

 

Drugs and services provided by professionals not covered by Medicare (such as dental services and vision care services) are the main categories of healthcare spending in the private sector (65.5% of private sector spending).

 

Private expenditure mainly consists of 2 items:

 

• citizens' spending
• private health insurance

 

In 1988, per capita spending on healthcare, directly supported by families, was $ 278. In 2017 it reached $ 973.

 

Over the same period, private health insurance spending per person grew from $ 139 to $ 824.

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4 Tidbits on healthcare spending in Canada

1. Canadian per capita expenditure on health care is among the highest internationally, in line with Australia, France and the Netherlands
2. Healthcare expenditure in Canada is above the Organization for Economic Cooperation and Development (OECD) average
3. The share of public sector-funded healthcare spending in Canada (70%) is lower than the OECD average (73%).
4. Canada's total healthcare expenditure as a percentage of GDP (10.7%) is higher than the OECD average (8.8%)

Source: Canadian Institute for Health Information

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Source: Canadian Institute for Health Information

 

The provincial and territorial plans can present enormous differences between them in relation to health expenditure. The reasons are geographic and demographic, but also economic and political.

 

Provinces and Territories may discretely provide, and according to their terms and conditions, a wide range of other programs and services than those insured by Medicare, such as coverage for prescription drugs, non-surgical dental care, ambulance services, and optometric services.

 

These services are often aimed at specific population groups (for example, the elderly, children and those who receive social assistance), with funding levels and coverage that vary from one Province or Territory to another depending on the policies adopted.

 

However, many provinces are activating important infrastructure investments in hospitals and in expanding the health services provided, also working on prevention.

 

Healthcare expenditure in Canada per person divided by Provinces and Territories (forecast for 2019)

 

Source: National Health Expenditure Database, Canadian Institute for Health Information

 

Aging population in Canada

 

Although it is not the main factor in the increase in the costs of Canadian health expenditure, the progressive aging of the population which will constantly increase future health expenditure must also be kept in mind. Population aging is expected to continue to contribute approximately 1 percentage point per year to total healthcare expenditure in the near future, approximately $ 2 billion a year more.

 

The Canadian population is made up of around 35.7 million people with a significantly younger demographic structure compared to European demographic models.

 

• The average age in Canada is 40.8 years. In Italy it is 45.7 years old.

• Canadians over the age of 65 represent 12% (4.5 million) of the population. In Italy they are 23%.

• In Canada 16% of people are under 15 years old. In Italy they are only 13%.

 

Why are these percentages important?

 

To calculate the demographic dependency ratio and highlight the age structure of the Canadian population. This ratio measures the size of the population depending on the working age population.

That is the youth population (from 0 to 19 years) plus the elderly population (from 65 years onwards) compared to the population of working age (from 20 to 64 years).

 

That is the youth population (from 0 to 19 years) plus the elderly population (from 65 years onwards) compared to the population of working age (from 20 to 64 years).

 

If the share of the young population is sufficiently large, we imagine that in the future it will be sufficient to maintain the pension and health care system. Otherwise, as we experience in Europe, the risk is lowering the level of health protection.

 

The population dependency ratio in Canada is certainly lower than in other similar countries in terms of economic structure. In 2016 it was 60.2%, with 33.9 young people and 26.3 elderly people per 100 workers.

 

However, it is expected that by 2056 there will be 50 seniors to assist for every 100 workers.

 

How the healthcare system is organized in Canada

 

As in Italy, there is also a family doctor in Canada, to whom we turn for first-level health care. Every Canadian can freely choose his own general practitioner or GP, as family doctors are called in Canada. Usually it is done on the advice of friends and relatives, by asking for a name from the local hospital or by searching on specific websites such as Health Care Connect or Doctor Search.

 

Primary Health Care Services

 

The first level of health care has the dual task of:

1. provide first contact health care services directly
2. coordinate other patient health services when more specialized interventions are needed, such as specialist visits or hospitalization

 

Basic health care services include:

• prevention and treatment of common diseases and injuries
• basic emergency services
• referral and coordination with other levels of assistance, such as hospital and specialist care
• primary mental health care
• palliative and end-of-life care
• health promotion
• the healthy development of the child
• assistance to primary maternity
• rehabilitation services

 

And in case you need a specialist service or hospitalization?

 

Secondary Services

 

Secondary public health services are provided to resident citizens through a governance structure and methods established by the individual Provinces and Territories.

 

The most common governance model is that of health regions, Regional Health Authorities (RHAs), which local governments use to administer and provide public health care to all Canadian residents.
 

As for the management of hospitals, most are administered by boards of directors, voluntary organizations or by the regional health authorities themselves.

 

Hospitals are generally financed through global annual budgets that set overall spending targets or limits negotiated with provincial and territorial health ministries or with an authority or regional health council.

 

The specialist services covered by public assistance are established by individual local plans. All the rest is the responsibility of individuals or private health insurance companies.

 

As for home and continuous care services, not covered by the Canada Health Act, the provinces and territories provide and pay for some according to different rules and programs specific to each Province / Territory.

In general, the health care services provided in the long-term care facilities are borne by the provincial and territorial governments, while the costs of board and lodging are borne by the individual. In some cases, payments for board and lodging are subsidized by provincial and territorial governments.

 

Number of physicians per 100.000 population, by specialty, Canada, 1978 to 2019

 

 

 

Source: Physicians in Canada, 2019

 

 

Waiting times for health services

 

The number of doctors in Canada is increasing and reached 90,000 in 2018. Family doctors represent between 50% and 53% of the doctors' workforce.

 

241 doctors per 100,000 people, 122 family medicine and 119 specialists, however, do not seem sufficient, above all, to satisfy the health demand considered a right and therefore covered by Medicare.

 

The relationship between doctors and residents often results in waiting times that are too long to access the requested service. Waiting times have more than doubled in the past 20 years, according to the Fraser Institute's Waiting Your Turn report that has been examining medical services in Canada for two decades.

 

It is estimated that in 2019, Canadians were waiting to receive over 1 million benefits.

 

 

According to the report, 20.9 weeks is the average time that elapses between the referral of the patient to the specialist by the family doctor to receive the health treatment. A week longer than in 2018.

 

In 1993, the waiting time was 9.3 weeks.

 

Waiting times are the result of two components:

• The weeks that pass since the GP prescribes the need to see a specialist and the visit itself must be considered
• And, secondly, the weeks between the appointment with the specialist and the eventual treatment necessary for the patient

 

According to the performances, therefore, the waiting times can present enormous differences. Between the prescription of a GP and an orthopedic surgery, more than 39 weeks pass, more than 25 weeks for neurological surgery, while patients waiting for medical oncology treatments begin treatment in 4.4 weeks.

 

Patients also have significant waiting times for different diagnostic technologies in all provinces: 4.8 weeks for a computed tomography scan, 9.3 weeks for an MRI scan and 3.4 weeks for an ultrasound scan.

 

There are also strong differences between local health systems.

 

The difference in waiting for patients is more than double between Ontario or Québec (about 16 weeks) and the Province of New Brunswick or Prince Edward Island (39.9 and 49.3 weeks).

 

 

Coronavirus health emergency (Covid-19)

 

Canada, like most countries in the world, is facing the health emergency that arose from the spread of Coronavirus.

 

The number of cases is constantly monitored and it is possible to follow the trend of infected people and deaths on government sites.

 

How did the Canadian health system respond?

 

First of all, Canada has adopted, under the COVID-19 Emergency Response Act, the Public Health Events of National Concern Payments Act in force until September 30, 2020, thanks to which, once established by the Minister of Health that exists a public health event of national interest, that is, an extraordinary event that constitutes a risk to public health, the Consolidated Revenue Fund may be available.

At the request of a federal minister and with the collaboration of the Minister of Finance and the Minister of Health, it is thus possible to release all the funds necessary for any action in response to that public health event of national interest, such as:

• Purchase medical supplies
• Assist Provinces and Territories to cover security costs and emergency response needs
• Canada provide income support, including emergency response subsidy in Canada
• finance federal public health programs or cover expenses incurred by federal departments and agencies

 

Learning from SARS

 

Secondly, Canada tried to put to use the painful lesson learned with SARS in 2003 which killed several dozen, finding the government completely unprepared for the health crisis.

 

In collaboration with provincial and territorial governments and international partners, it therefore immediately adopted a plan to minimize the health, economic and social impacts of Covid-19.

 

The framework of the guidelines was in fact largely outlined, that is, that emerged at the time of SARS on the basis of a series of recommendations sent by the experts in a report entitled "Learning from SARS" and which led to legislation on the subject, specific plans dedicated infrastructure and resources to help ensure that the country was prepared to detect and respond to the outbreak of a new pandemic.

 

Some examples of the measures taken were:

 

• The creation of the Public Health Agency of Canada, which monitors and responds to epidemics that could endanger the health of Canadians
• The appointment of a Chief Public Health Officer, who advises the Canadian government and Canadians on measures to be taken to protect their health, working in close collaboration with key health care managers in the provinces and territories.
• The development of a Canadian pandemic flu preparation: planning guide for the healthcare sector, which sets out guidelines for preparing for and responding to a pandemic.
• Enhancement of diagnostic capacity in the National Microbiology Laboratory.
• Strengthening relations with the World Health Organization and other international partners, such as the US Centers for Disease Control and Prevention.

 

 

The measures taken to respond to the spread of Covid-19

 

The federal government  joined with over $ 1 billion in public health measures local health plans in response to the spread of the virus.

 

$ 50 million was directed to support initial actions, such as border and travel measures and the activation of the Health Portfolio Operations Center and the National Microbiology Laboratory.

$ 2 million was paid to the World Health Organization for support for the effort to contain the epidemic.

$ 50 million was spent on information and citizen measures.

 

The government of Canada will also provide $ 500 million to provinces and territories to cope with measures to adjust the health system to the risk of contagion.

 

It was guaranteed that financial problems will not be an obstacle for hospitals and health systems that must make the necessary preparations to mitigate risk.

 

Federal, provincial and territorial governments are also working to ensure that Canada has the necessary health supplies and the Government of Canada will invest $ 50 million in the purchase of personal protective equipment (PPE) and other medical supplies and equipment.

 

Research has not been neglected, as a support to the global strategy focused on tightening the international scientific community around the common goal of containing the virus.

 

The federal government has allocated $ 27 million to support 47 research teams across Canada.

 

And additional $ 275 million will be invested in research on the development of vaccines, antiviral and clinical studies.

 

 

Source: Governement of Canada

 

According to the National Health Expenditure Trends 2020, at the beginning of October 2020, health funding related to Covid-19 announced by the federal, provincial and territorial levels of government amounted to more than $ 29 billion.

 

The Covid-19 vaccination plan in Canada

In response to the Covid-19 pandemic, Canada too, as is happening in most of the affected countries, has developed a vaccination plan.

 

The vaccine will be accessed free of charge by anyone living in Canada, including the non-Canadian population.

Canada's health care system is confirmed to be based on an universalistic principle.

 

2 vaccines approved so far:

• the Pfizer-BioNtech COVID-19 vaccine
• the Moderna Vaccine COVID-19

 

The plan is to proceed, compatibly with available supplies, gradually vaccinating high-risk groups first:
 

• residents and staff of shared living settings who provide care for the seniors
• adults aged 70 or over with priority for those over 80, then proceeding by decreasing the age limit by 5year increments to age 70 years as supply becomes available

• healthcare workers who have direct contact with patients, including those working in healthcare settings and personal support workers
• adults in indigenous communities

 

As additional COVID-19 vaccine(s) and supplies become available, the following populations should be offered vaccinations:

• health care workers not included in the initial rollout
• residents and staff of all other shared living settings, such as:
  • homeless shelters
  • correctional facilities
  • housing for migrant workers
• essential workers who face additional risks to maintain services for the functioning of the society

According to the estimate of the Canadian government, assuming that there are no problems related to the supply, by September 2021 all those for whom vaccination is recommended will be vaccinated.

 

How is the vaccination machine organized?

 

Provinces and territories are working on detailed plans for the implementation of vaccination for their residents and each local authority has made available updated data on the doses received and administered.

 

Here you can select the province or territory and access the relevant updated data.

 

Currently (as of January 21, 2021) the federal government has transferred over 1 million doses to territorial governments.

 

In fact, the territorial governments are responsible for the vaccination distribution process: from planning to conservation, to administration.

 

Provinces and Territories establish how to organize the sequence of initial and subsequent doses and how to manage, monitor and share data on coverage and any problems that have emerged.

 

Source: Canada’s COVID-19 Immunization Plan

 

 

CTVNews.ca is tracking the administration of vaccine doses and has made a map where progress can be viewed both nationally and locally.

 

A vaccine Made in Canada

 

Among the investments planned by Canada, there is also support for national projects in the biology sector to support Canada's vaccination response to Covid-19.

 

The Prime Minister, Justin Trudeau, announced an investment that will reach $ 173 million from the Strategic Innovation Fund (SIF) directed to Medicago, a biopharmaceutical company in Quebec City.

The project has a total value estimated at $ 428 million and will advance clinical trials of the company's plant-based vaccine. It will also establish a large-scale vaccine and antibody manufacturing facility to increase Canada's national organic production capacity.

 

The agreement with Medicago provides for a supply of up to 76 million doses of their Covid-19 vaccine candidate, enough to vaccinate 38 million people.

 

Additionally, a $ 18.2 million investment will go to Vancouver-based biotechnology company Precision NanoSystems Incorporated (PNI) to promote the Made in Canada COVID-19 vaccine that the company is developing.

 

Canada is also funding the Industrial Research Assistance Program (IRAP) with $ 23.2 million for the advancement of 6 additional COVID-19 vaccine candidates currently in various stages of clinical studies.

 

 

*Journalist and Digital Human Consultant

 

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References

• Government of Canada Canada's Health Care System

• Statistics Canada.  Table  17-10-0133-01   Dependency ratio (2016 Census and administrative data), by age group and sex for July 1st, Canada, provinces, territories, health regions (2018 boundaries) and peer groups

• Health Canada. Canada Health Act Annual Report 2018-2019

• Organization for Economic Co-operation and Development. Health at a Glance 2019 OECD INDICATORS

• Canadian Institute for Health Information National Health Expenditure Trends

• Canadian Institute for Health Information Physicians in Canada, 2019

• Statistics Canada - Dependency ratio

• Istat Indicatori demografici 2019

• Fraser Institute Waiting Your Turn Wait Times for Health Care in Canada, 2019 Report

• Salute Internazionale Covid-19 in Canada

• Salute Internazionale Il sistema sanitario canadese

• The Lancet. Canada and COVID-19: learning from SARS.

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