Accessibility and the Canadian health care system: squaring perceptions and realities
Introduction
The Canadian health care system, which is often held up as a model of a public, universal and comprehensive system in international comparisons, went through an unprecedented series of changes in the 1990s as the federal government reduced its financial support to the provinces and the provincial governments responded by restructuring health care delivery, sometimes even in open defiance of the Canada Health Act (CHA). Two kinds of impacts have resulted. For the federal and provincial governments and the policy-making community, the tensions of the 1990s have resulted in a series of high profile studies and commissions [1], [2], [3], [4]. Each of these reports offers a set of prescriptions, which claim to maintain the principles of the CHA while suggesting various ways accessibility to health care services can be improved. For Canadians in their everyday lives, there is a growing perception that health care delivery is becoming less accessible as waiting times to see a physician or receive hospital services grow longer, services disappear altogether or become privatized in their communities.
Through the 1990s, the perceptions of Canadians and their health care behaviour were measured in two ways. National polling organizations periodically asked Canadians whether they felt accessibility was declining and whether they continued to support the principles of the CHA. On the other hand, the federal government through Statistics Canada launched an ambitious data collection exercise to measure scientifically Canadians’ utilization, access and barriers to health services under the rubric of the National Population Health Survey (NPHS).
The goal of this paper is to examine the contrasting evidence between the public opinion polls of the 1990s and the results of the 1998/99 NPHS as a way of understanding the competing policy options being explored by the federal and provincial governments. To accomplish this goal, the paper is divided into four sections. The next section is dual purpose. It discusses the conceptual issues surrounding accessibility. We then go on to examine the policies that cover accessibility in the Canadian context. In Section 3, we illustrate the perceptions of Canadians through some examples from recent Canadian public opinion polls. In Section 4, we turn to the NPHS as an alternative source of data to examine accessibility to health care in Canada. In this section, we describe the survey and the particular questions chosen for analysis. We also discuss the analytic techniques used in the paper. The results of the analysis are presented. We conclude by arguing that the analysis of the NPHS suggests that most Canadians did not indicate that they had problems accessing health care services at the end of the 1990s, but among those who did, the barriers to accessibility are linked to specific socio-economic characteristics of the individuals. This does not, however, resolve the old political axiom that if people perceive there is an issue then there is an issue. In turn, this suggests that those Canadian politicians, policy-makers and even the Canadian public who continue to believe in the preservation of the CHA face a serious political challenge in squaring perceptions with realities.
Section snippets
Contextualizing accessibility
A review of the literature across different disciplines reveals that conceptualizations of accessibility to health care services encompass many diverse themes. As Harding [5] notes, access to health care is not a well-defined term and ideas of access range from the identification of need for care to the actual delivery of health care services. For example, early research on accessibility, such as the work of Donabedian [6] emphasizes two important aspects of accessibility. Socio-organizational
The public speaks out
The lack of clarity in policy is reflected in how Canadians responded to these issues as evidenced in public opinion polls in the 1990s. National polling organizations periodically asked Canadians whether they felt accessibility was declining and whether they continued to support the principles of the CHA. It is remarkable how consistent the Canadian public was in expressing their views. A review of public opinion polls prepared by Mendelsohn [19] for the Commission on the Future of Health Care
Measuring accessibility using the NPHS
The NPHS is both a cross-sectional and longitudinal household survey that has been conducted every 2 years since 1994 by Statistics Canada.2 Within the NPHS98/99 [26], there are two cross-sectional micro-data files
Results
To place the analysis in context, according to the 1998/99 NPHS approximately 87% of Canadians indicated that they saw a family doctor/general practitioner at least once in the previous 12 months. As Fig. 1 illustrates, only a very small proportion (5.9%) of the Canadian population, aged 25 years and older, reported not receiving care when needed in 1998/99. Although when we compare this value for previous years of the NPHS, we observe an increase over time. As shown in Table 1, a slightly
Discussion
The goal of this paper was to examine perceptions of accessibility in public opinion polls and actual accessibility as measured through the NPHS. Public opinion polls demonstrate that while Canadians want to preserve the principles of the CHA, a majority of Canadians are losing confidence in their health care system. In contrast, the results from the NPHS reveal that only 6% of Canadians aged 25 years and older experienced accessibility problems in 1998/99.
The differences in actual
Conclusions
As suggested in 1 Introduction, 2 Contextualizing accessibility, there are competing views among policy makers about the viability of the Canadian health care system as defined by the principles of the CHA and within the CHA how accessibility ought to be interpreted and used in delivering health care. With the exception of a small group on the extreme right of the political spectrum who would do away with the CHA in its entirety and would adopt a US model, much of the debate is among those who
References (28)
Closing rural hospitals in Saskatchewan: on the road to wellness?
Social Science and Medicine
(1999)- et al.
Socio-economic status and the utilisation of physicians’ services: results from the Canadian national population health survey
Social Science and Medicine
(2000) - Kirby M. The health of Canadians—the federal role interim report: vol. 1. The Story So Far. Ottawa, Ontario: standing...
- Mazankowski D. A framework for reform: report of the Premier's Advisory Council on Health. Edmonton, Alberta: Ministry...
- Romanow R. Shape the future of health care. Ottawa: interim report of the commission on the future of health care in...
- Saskatchewan. Healthy people. A healthy province. The action plan for Saskatchewan health care. Regina, Saskatchewan:...
- Harding O. What is access? What are ‘whole systems’? British Medical Journal Online Editorial, October 4,...
Models for organizing the delivery of personal health services and criteria for evaluating them
Millbank Memorial Fund Quarterly
(1972)- et al.
A framework for the study of access to medical care
Health Services Research
(1974) - et al.
Accessibility and utilization: geographical perspectives on health care delivery
(1984)
Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente
British Medical Journal
Parents’ perception of primary care: measuring parents’ experiences of pediatric primary care quality
Pediatrics
Does managed care enable more low income persons to identify a usual source of care?
Medical Care
Access to health care and community social capital
Health Services Research
Cited by (67)
Measuring accessibility to hospitals by public transport: An assessment of eight Canadian metropolitan regions
2020, Journal of Transport and HealthCitation Excerpt :No one may be discriminated against on the basis of such factors as income, age, and health status.” ( Parliament of Canada, 1985) There has, however, been extensive debate on how to interpret this notion of accessibility, both in government and academia (Wilson and Rosenberg, 2004). In academia, the interpretation of accessibility has generally fallen into two distinct categories: potential and realized access to healthcare (Guagliardo, 2004; Wilson and Rosenberg, 2004).
Evaluation of an emergency department to outpatient parenteral antibiotic therapy program for cellulitis
2019, American Journal of Emergency MedicineCitation Excerpt :Patients discharged from the emergency department (ED) can receive OPAT follow up in a number of settings: return to the ED, a family physician clinic, a homecare clinic run by nurses, or a dedicated OPAT clinic. Due to difficulties with primary care access [7] and associations between ED overcrowding and increased adverse events [8], an ED-to-OPAT clinic program may be a preferred option due to important advantages: 1) decreased hospital admissions; 2) increased patient convenience; and 3) decreased ED visits. ED-based studies have shown that intravenous antibiotics are frequently administered [9,10].
Understanding barriers to health care access through cultural safety and ethical space: Indigenous people's experiences in Prince George, Canada
2018, Social Science and MedicineCitation Excerpt :“Reasonable access” is understood as economic and physical access; the former meaning that clients do not have to pay for medically necessary services covered under provincial public health insurance plans, and the latter defined by the “where and as available” rule, meaning that every insured person will not, for example, have access to identical services in small, remote towns and large urban centres. These rules are intended to preclude discrimination, whether based on fees incurred at the point of service delivery or on identifiers such as age, sex, or racialization (Health Canada, 2017; Wilson and Rosenberg, 2004). Thus, the Canadian government provides funding for health care services, but provinces administer and deliver the services.
Peer helpers' struggles to care for "others" who inject drugs
2015, International Journal of Drug PolicyCitation Excerpt :Despite the Canadian Health Act's assurance of universality, concerns pertaining to accessibly are not uncommon (Wilson & Rosenberg, 2004).
Older Immigrants' Access to Primary Health Care in Canada: A Scoping Review
2019, Canadian Journal on Aging