Accessibility and the Canadian health care system: squaring perceptions and realities

Abstract

The 1984 Canada Health Act (CHA) is the major piece of Federal legislation that governs health care accessibility in the provinces and territories. According to the CHA, all provinces and territories in Canada must uphold five principles in order to receive federal funding for health care (universality, comprehensiveness, portability, public administration, and accessibility). In Canada, there are competing views among policy makers and consumers about how the CHA's principle of accessibility should be defined, interpreted and used in delivering health care. During the 1990s, the health care perceptions of Canadians and their health care behaviours were measured through both public opinion polls and Statistics Canada's National Population Health Survey (NPHS). The goal of this paper is 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 have experienced accessibility problems. Among those who report access problems, the barriers to accessibility are linked to specific socio-economic, socio-demographic and health characteristics of individuals. We discuss these findings in the context of the current debates surrounding accessibility within the CHA and the Canadian health care system.

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.