1. Universality of coverage
The provinces have to cover 100 per cent of their residents for hospital and physicians’ services.
2. Portability of coverage
The provinces have to cover their residents for care in other provinces at the rates that pertains in other provinces. They are supposed to cover their residents while out of the country at least at the rates that would have pertained in their home province.
3. Reasonable accessibility to services
The provinces are to ensure that services are “reasonably accessible” and that financial charges or other barriers do not impede access. This criterion also requires the provinces to pay reasonable compensation to their health professionals.
4. Comprehensiveness of services
The provinces are supposed to cover all “medically necessary” services provided by doctors or within hospitals. This criterion is actually a misnomer because community services (such as home care) are not covered and neither are the services of other providers (except dental services within hospitals – a rare event these days).
5. Public administration
The provinces have to administer their health insurance programs either themselves or through a body that is accountable to the provincial government. This criterion is also a bit of a misnomer because it expressly forbids neither for-profit insurers acting on contract with a province nor for-profit providers of services.
Source: Rachlis, M. (2004). Prescription for Excellence: How Innovation is Saving Canada’s Health Care System. Toronto: HarperCollins Publishers Ltd.
A Summary of Canada’s Health Care System
Canada's publicly funded health care system is best described as an interlocking set of ten provincial and three territorial health insurance plans. Known to Canadians as "medicare," the system provides access to universal, comprehensive coverage for medically necessary hospital and physician services. These services are administered and delivered by the provincial and territorial (i.e., state or regional) governments, and are provided free of charge. The provincial and territorial governments fund health care services with assistance from the federal (i.e., national) government.
What Happens First (Primary Health Care Services)
When Canadians need health care, they generally contact a primary health care professional, who could be a family doctor, nurse, nurse practitioner, physiotherapist, pharmacist, etc., often working in a team of health care professionals. Services provided at the first point of contact with the health care system are known as primary health care services and they form the foundation of the health care system.
In general, primary health care serves a dual function. First, it provides direct provision of first-contact health care services. Second, it coordinates patients' health care services to ensure continuity of care and ease of movement across the health care system when more specialized services are needed (e.g., from specialists or in hospitals).
Primary health care services often include prevention and treatment of common diseases and injuries; basic emergency services; referrals to and coordination with other levels of care, such as hospital and specialist care; primary mental health care; palliative and end-of-life care; health promotion; healthy child development; primary maternity care; and rehabilitation services.
Doctors in private practice are generally paid through fee-for-service schedules negotiated between each provincial and territorial government and the medical associations in their respective jurisdictions. Those in other practice settings, such as clinics, community health centres and group practices, are more likely to be paid through an alternative payment scheme, such as salaries or a blended payment (e.g., fee-for-services plus incentives). Nurses and other health professionals are generally paid salaries that are negotiated between their unions and their employers.
When necessary, patients are referred to specialist services (medical specialist, allied health services, hospital admissions, diagnostic tests, prescription drug therapy, etc.).
What Happens Next (Secondary Services)
A patient may be referred for specialized care at a hospital, at a long-term care facility or in the community. The majority of Canadian hospitals are operated by community boards of trustees, voluntary organizations or municipalities. Hospitals are paid through annual, global budgets negotiated with the provincial and territorial ministries of health, or with a regional health authority or board.
Alternatively, health care services may be provided in the home or community (generally short-term care) and in institutions (mostly long-term and chronic care). For the most part, these services are not covered by the Canada Health Act; however, all the provinces and territories provide and pay for certain home care services. Regulation of these programs varies, as does the range of services. Referrals can be made by doctors, hospitals, community agencies, families and potential residents. Needs are assessed and services are coordinated to provide continuity of care and comprehensive care. Care is provided by a range of formal, informal (often family) and volunteer caregivers.
Short-term care, usually specialized nursing care, homemaker services and adult day care, is provided to people who are partially or totally incapacitated. For the most part, health care services provided in long-term institutions are paid for by the provincial and territorial governments, while room and board are paid for by the individual; in some cases these payments are subsidized by the provincial and territorial governments. The federal department of Veterans Affairs Canada provides home care services to certain veterans when such services are not available through their province or territory. As well, the federal government provides home care services to First Nations people living on reserves and to Inuit in certain communities.
Palliative care is delivered in a variety of settings, such as hospitals or long-term care facilities, hospices, in the community and at home. Palliative care for those nearing death includes medical and emotional support, pain and symptom management, help with community services and programs, and bereavement counselling.
Source: Health Canada