At present, availability and coverage of extended health services varies markedly between provinces and territories.

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At the time the language of the original legislation was developed the Canada Health Act was based on two earlier pieces of legislation, the Hospital Insurance and Diagnostic Services Act and the Medical Care Act , it was expected that most care would be delivered in hospitals and by physicians. The restriction of insured services to "medically necessary services" provided by hospitals and physicians has skewed subsequent patterns of service delivery in Canada.

It has reinforced the position of acute care and institutional services at the expense of community and preventive services, and defined care by who provides it, and where it takes place, rather than whether care is needed Hurley et al. While a population health approach results in a focus on providing services in the community and treating sick people at home, this trend has the effect of "off-loading" expenses from the publicly funded system to third party payers or to individuals.

Inequities in provision of non-insured services, which include dental services, vision correction, prescription drugs and counselling or mental health services, have been highlighted as an area of growing concern Federal, Provincial and Territorial Advisory Committee on Population Health, Canadians who do not have supplementary insurance coverage through employee plans or social assistance programs, for example may not be able to afford some services. Some services, such as health outreach or education programs provided outside of the formal health system, are not insured services and so do not fall under the scope of the Act.

These initiatives form a crucial component of a comprehensive system that addresses the need to promote and protect, as well as restore, health. The "Canadian Health System" is not a federal health system; rather, it is a collection of provincial systems.

Provinces and territories are responsible for the planning, administration and delivery of health services. However, there is a national plan in that all provincial and territorial plans are linked through adherence to national principles set at a federal level. Provincial and territorial plans must meet certain criteria to qualify for full transfer payments from the federal government.

The federal government also retains responsibility for certain populations and health services; two of these are health care to registered First Nations and Inuit people, and to refugee claimants. Aboriginal persons are covered for hospital and medical costs by provincial health insurance plans in the same way as other Canadians.

However, registered Indians and Inuit who are not divided into status or non-status categories are also eligible for health programs administered by the First Nations and Inuit Health Branch of Health Canada. Relative responsibilities of the federal and provincial governments are poorly defined. Shared responsibility has been the source of confusion and ongoing debate since the British North America Act defined health care as a provincial responsibility and "general care of Indians" as a federal responsibility.

Historically, the federal government has had a special responsibility for health care for A boriginal people. In , the Indian Health Policy established a framework for delivery of Indian and Inuit health programs. This policy acknowledged the "special relationship of Indian people to the federal government'" and recognized the importance of socio-economic, cultural and spiritual development in addressing underlying causes of poor health.

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The federal government and Aboriginal peoples disagree on health care as a treaty right. The position of the Assembly of First Nations AFN is that health is a treaty right, and an element of First Nations' inherent right to self-government. The AFN also maintains that provision of health services is an area of undefined federal fiduciary obligation. The federal government has agreed to provide health care to First Nations and Inuit people where this would not otherwise be available, which excludes off-reserve Aboriginal peoples from federal health services and programs.

This has led to disparity in the type and extent of coverage of Aboriginal persons by status. In , the Health Transfer Program was initiated; the intent was to transfer control of federal Indian health services to First Nations people themselves. Transfer is to occur within the existing legal framework and funding base. The health transfer process places the discussion of health services for First Nations peoples within a different context from that of other communities, and has important implications for the issue of access to health care.

Prior to , refugee claimants Footnote 2 to Canada were not eligible for heath care coverage, although some provinces had made some arrangements for care. The Interim Federal Health Program, administered by Citizenship and Immigration Canada, is intended to ensure emergency and essential health services for needy refugee claimants and those refugees in Canada who are not yet covered by provincial health plans.

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In the discussion of access to health care by underserved populations, the human rights legislation of a country must also be considered. In Canada there have been few challenges to interpretation of access as simply the absence of explicit financial barriers to health care. Claims involving rights of access to health care are principally based on interpretations of the Canadian Charter of Rights and Freedoms, the Canadian Human Rights Act , provincial human rights acts, and the Canada Health Act. A recent ruling by the Supreme Court of Canada found that absence of communication resulted in substandard care and determined that hospitals were required to provide interpreters for deaf patients Eldridge v.

British Columbia [Attorney General], There are also requirements that facilities be physically accessible to persons with disabilities. The establishment of Canada's system of universal health insurance was part of a larger commitment to social welfare programs. These programs grew out of a philosophy of mutual aid and a willingness to protect the less fortunate. The health system not only removes financial barriers, but also becomes part of the environment of social support. They may be served by different organizations and government departments, and may have different rights to access under the law.

Even where issues of concern may be similar e. While the discussion of Aboriginal health services takes place within the context of the right to self determination of First Nations peoples, the issues facing immigrants and refugees are often seen as "newcomer" issues that will resolve with time.

Similarly, issues of access of gay, lesbian and bisexual persons, or of persons with disabilities are also often seen as "separate" issues, and of concern to different stakeholders. Canada's health system, like that of most countries, has undergone significant restructuring over the past several years, mainly in response to concerns about escalating health care costs. Actions taken to contain costs have resulted in concerns about equity, concerns that resource allocations should be made consistent with the needs of populations, and concerns that inequitable distribution of health care resources is resulting in geographically remote and socially disadvantaged groups having less access to appropriate care.

Many provinces have undertaken commissions to review health care systems. A number of recurring themes have emerged from such reviews.

These include: broadening the definition of health; shifting the emphasis from curing illness to health promotion and disease prevention and from institutional to community care; increasing opportunities for participation of consumers; regionalization; improved human resource planning with an emphasis on alternative remuneration for physicians ; increased coordination of services,; increased funding for health services research; and evidence based decision making Mhartre and Debber, ; Hutchinson and Abelson, ; Closson and Catt, Responding to these issues may improve service to underserved populations, but the issue of access has not been addressed.

Issues of concern to diverse and disadvantaged groups may in fact be lost in the restructuring process.

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For example, regionalization, the devolution of care to smaller health authorities , has been proposed as a potential benefit to vulnerable populations. By moving decision making closer to the health care user, in theory, services should become more responsive to local needs. However, there are several challenges. A major emphasis in heath reform has been to ensure that health care costs can be maintained at sustainable levels. Adoption of a population health approach has focused attention to the need to shift the emphasis within current services towards prevention, shift funding within the system to more "upstream" services, and to address the underlying causes of ill health.

In reality, however, many community-based programs focusing on disease prevention and health promotion have experienced the same financial cutbacks as acute care services. These programs, which provide services such as health interpretation or preventive health education, play a leading role in facilitating access for underserved gr ou ps. It is not clear how emerging concerns about general health access waiting lists, private clinics, early hospital discharge, or access to home care services may affect populations who are already considered underserved.

While there is widespread recognition that certain populations within Canadian society are underserved, there is no consensus on what this means.

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Three concepts that are integral to the discussion of service provision to underserved groups are "underservice", "equity" and "access". Underservice is defined by various writers in different ways, and may be used to describe problems with service availability, service access, or the quality of treatment obtained.

In this paper, underservice refers to an increased likelihood that individuals will, because of their membership in a certain population: experience difficulties in obtaining needed care; receive less, or a lower standard of care; experience differences in treatment by health personnel; receive treatment that does not adequately recognize their needs; or, be less satisfied with health care services. Many underserved populations share the characteristics of lower income and social disadvantage. The evidence for the effect of these determinants on health status has been the subject of extensive study and will not be the focus of discussion here.

However, underserved populations cannot be defined by low income alone. Some underserved populations e.

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They may present with health conditions which are not as well managed by the formal health system e. They are at risk for decreased health status, and are likely to face non-financial barriers to health care access as well as discriminatory treatment within society as a whole and the health system. Members of other groups such as visible minorities, gay, lesbian and bisexual may face inequitable treatment by the health care system, even if they are not of low economic status.

Not all members of underserved groups are poor or less educated, indicating the importance of other barriers that may be independent of socioeconomic factors.

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A person may share characteristics with one or several groups defined as underserved. People of lower socioeconomic status and who are underserved for some other reason are further jeopardized. Addressing inequities experienced by underserved populations is a fundamentally different issue than ensuring equitable distribution of the "same" resources across geographic regions. The issue of service provision for "underserved areas" is by and large an issue of supply and distribution of health personnel and services, while the issues facing underserved populations are more a problem of access.

Underservice due to geographic location, and underservice due to membership in a specific population differ in a number of ways: the factors contributing to the problem of underservice, the actual problems of "access" which result, strategies for measuring need, the scope of effect of the access barriers, and potential solutions. Equity in health refers to the fair and just distribution of resources. The concept of equity differs from that of equality ; the measure of health care equity is not that every one receives the same service, or the same number of services, but that the service provided is based on need.

In Canada, equity is generally described as "equal access or equal service for equal need". It is recognized that those who are sicker, or face greater risk to health, should receive a greater intensity of service, and it follows that lower income groups should receive more services. While care in Canada is related to need, not income, the question has been raised as to how much more care those of lower health status should receive compared to those in better health.

Some writers have suggested that while more services are provided to those at the lowest income level, the differential does not necessarily correspond with observed differences in health status Roos et al. More research is needed in this area. Simply providing equal service for equal need may not be sufficient to achieve equity. This is best illustrated by example.