A Vision for Rural Health

Medicare (French: assurance-maladie) is a common name for Canada’s publicly-funded, single-payer health care system. In 1962, Saskatchewan was the first province to introduce a universal, provincial medical insurance plan to provide physician services to all residents. In 1966, the federal government passed the Medical Care Act, and within six years, all the provinces and territories had universal physician services insurance plans. This is what is now called universal health coverage. 

After many reforms, the Canada Health Act (CHA) was passed in 1984. It is the federal law that sets out publicly funded health care insurance for all Canadians. The CHA lays out the vision for Canadian health-care policy: 

 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.

This means that when Canadians use public health services, the cost are covered through provincial health insurance plans. Each province is responsible for planning and operating a public health-care system that covers basic health care. The provinces receive funds from the federal government to do this. They must meet the criteria and conditions of the CHA to receive the full federal cash contribution for provincial health-care services.  

Universal health coverage is the hallmark of Canada’s health-care system and it is essential to create fair access to care for all Canadians.  

In Canada, provinces and territories deliver health-care services, guided by the Canada Health Act. Health-care services include insured hospital care and primary health care, such as physicians and other health professional services. Like all residents, Indigenous peoples access insured health services through provincial and territorial governments.

Health Canada also provides health services to First Nations. The Non-Insured Health Benefits Program is Health Canada’s national health benefit program that covers benefit claims for a specified range of drugs, dental care, vision care, medical supplies and equipment, short-term crisis intervention, mental health counselling, and medical transportation for eligible Indigenous people.

An eligible recipient of the Non-Insured Health Benefits Program must be identified as a resident of Canada and one of the following:

1. A First Nations person registered under the Indian Act;
2. An Inuk recognized by one of the Inuit Land Claim organizations; or
3. An infant less than 18 months of age, whose parent is an eligible recipient.

Non-status First Nation and Métis people do not receive any health care benefits from the federal government. To learn more, Alberta Health Services has created a series of summaries on Indigenous Myths & Misconceptions, including correcting the misconception that all Indigenous people receive free health care.

More than two decades ago, the World Health Organization (WHO) introduced the concept of “social accountability” to create more equitable health care for all.  

WHO has defined the Social Accountability of Medical Schools as: 

 the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals, and the public.

As part of this social accountability mandate, medical schools have an obligation to engage and partner with rural communities and to train a skilled workforce that is willing and able to work in rural communities and address their pressing health needs.  

Canadian medical schools became early adopters of social accountability, and demonstration of social accountability is now included in the Canadian accreditation requirements. The Rural Road Map is an initiative that aims to enhance equitable access to health care and improve patient outcomes in rural and remote communities in Canada. The Rural Road Map reinforces the social accountability of medical schools in producing rural physicians. It encourages that all Canadian medical schools:  

• Admit students who are more likely to go into rural practice; 
• Develop programs that increase the number of rural students in medical schools; 
• Support undergraduate medical training that prepares medical students for rural practice; and 
• Offer medical students and resident physicians high-quality clinical and educational training in rural communities. 

These strategies are based on early research suggesting that physicians are more likely to practice in rural communities if they had: 

1. a rural upbringing;  
2. positive exposure to rural practice as a medical student;  
3. targeted post-graduate clinical experience in rural areas; and  
4. stated a preference for general or family practice primary care.  

Newer studies reaffirm that family physicians with rural backgrounds or rural experience during undergraduate or postgraduate medical training are more likely to practice in rural areas. The effects of multiple factors seem cumulative, and the duration of a rural training experience influences the likelihood of a family physician to take up and remain in rural practice. 

Another way to foster rural practice is to create medical programs with close links to rural communities. One example is the Northern Ontario School of Medicine (NOSM). Its program is grounded in the Northern Ontario health context. There is a strong emphasis on interprofessional education and integrated clinical learning that takes place in over 70 rural communities and many different health care settings. The school has a substantial percentage of medical students from Northern Ontario, including Aboriginal and Francophone students, and the percentage of medical graduates that have chosen family practice is high. The school also has a significant, positive socioeconomic impact in Northern Ontario. This suggests that rural focused programs are not only an effective strategy to build the rural health workforce, but that they have broader benefits to rural communities. 

Both medical schools in Alberta have programs that align with the rural social accountability mandate. You can read more under “the Pipeline to Rural Practice” in the Attraction and Retention section.

Despite Canada’s universal health care system, rural Canadians can have challenges  receiving health care in a timely manner. Many health services such as mental health services, specialist services, and hospitals, can be quite limited in rural communities. 

One factor that limits health care access in rural Canada is the shortage of trained health professionals that work in rural communities. For example, only 2 percent of physician specialists work in rural areas. This means that on average, fewer physicians and other health care providers (e.g., nurses, physical therapists, occupational therapists, etc.) are available per 1000 people in rural areas compared to urban areas. Improving access to health care in rural Canada is a high priority for all levels of government. 

In 2014, the College of Family Physicians of Canada (CFPC) and the Society of Rural Physicians of Canada (SRPC) joined to develop a Canada-wide rural health framework called the Rural Road Map. The goal of the Road Map is to strengthen the rural physician workforce; provide high-quality, culturally safe care; and improve access for all people living in rural communities across Canada. 

The Rural Road Map has 20 recommendations and 4 directions to improve rural health care. The directions focus on:  

• Reinforcing the social accountability framework of medical schools, that is, medical schools have to demonstrate positive effects of their education, research, service, and graduates on the health care and health of their communities 
• Aligning medical education with workforce planning so medical schools produce the right number of graduates to serve all rural communities 
• New models of how health-care providers practice in rural areas  
• A national rural research agenda

A task-force helps turn the Rural Road Map recommendations into coordinated, comprehensive, measurable, and sustainable actions. Although progress has been made on many key issues, much more remains to be done. Click here for the latest report card on progress made.

Improving rural health is complex and requires the participation of many stakeholders. Health professionals, policy-makers, health and education administrators, universities, and communities must work together to apply the recommendations in future policies, programs, and services. 

Examining access to health care is important to understand potential health-care issues or gaps. Two Canadian studies highlight the differences in health-care access between rural and urban communities. 

The first study analyzed data from the Canadian Community Health Survey, which included over 100,000 Canadians across 10 provinces. The study used several measures of access across a range of health-care services, including influenza vaccination in the last two years, number of consultations and wait times to see family and specialist physicians, and having a regular medical doctor.  

The second study used data from the same survey as well as physician billing data and the Hospital Mortality Database. 

Both studies classified the data on a continuum of urban to rural using the Statistics Canada definition of Metropolitan influenced Zones (MIZ). MIZ groups communities based on their access to urban centres (strong, moderate, weak, no MIZ). This allows for a more nuanced picture of health-care access by degree of urban influence.

Both studies found that people living in the most urban areas were more likely to have seen a specialist physician, but there were no differences in wait times to see a specialist. Fewer residents in the most rural communities (weak or no MIZ) received a flu shot or had a regular medical doctor. They also visited a dentist less frequently. On the other hand, rural residents had more frequent hospital stays than urban residents. 

A third study used newer data from the Canadian Longitudinal Study on Aging (CLSA). The CLSA is a national research study that follows participants from all 10 Canadian provinces over 20 years. The study collects comprehensive data and biological samples that will support a wide variety of aging-related research questions. The initial data collection occurred in 2015, and further data is collected every three years. The study uses a slightly different definition of rural; nevertheless, it confirmed the different patterns of health services use between urban and rural residents described in the previous two studies.

Differences in health services use between urban and rural residents are not necessarily bad or a sign that less services exist in rural areas. Many things influence how people access and use health services, including their needs and preferences. Transportation, distance, travel costs, and weather can also influence how rural people make decisions about health care. This means that policies and programs in areas other than health can have a big impact. Research on rural health issues is key to identify these factors that can improve how rural Canadians access and use health services.

It is clear that health equity is a large undertaking that cannot be achieved with a few policy changes. To broaden thinking and policy making approaches, the World Health Organization (WHO) put forward a guiding concept called Health in All Policies. Health in All Policies asks all levels of government to examine the potential intended and unintended health and social consequences of all policies. This implies that health equity is a responsibility of all sectors, not just the health sector.  

 Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care. – Robert Wood Johnson Foundation

One example of how Canada has used a Health in All Policies approach in the past is the reduction of death and disability from traffic accidents. Various policies related to road design, laws and enforcement for impaired driving, and transport regulation were implemented to increase efficiency and save money. However, these policies also contributed to a reduction in collisions and injuries, which then resulted in better health outcomes for Canadians.  

Dealing with the rise of chronic diseases – like heart disease, diabetes, and kidney disease – is another area where a Health in All Policies approach would be beneficial. When multiple sectors of government collaborate to solve issues of sedentary lifestyles, poor nutrition, workplace health and safety, and low literacy, we will see much greater benefits. These combined strategies would help to solve the problems underlying chronic disease, and possibly prevent future disease from occurring.  

A Health in All Policies approach may seem unrealistic because it is very different from the way our governments currently work. However, to achieve a large complex goal like health equity, we need big changes. Researchers have shown that a Health in all Policies approach aligns with Canadian values. The COVID-19 pandemic has also shown that our current methods of governance and wealth distribution are not sufficient to ensure the health and wellness of all. There is great potential for this concept if we can establish shared goals and commit to reach them. 

In 2016, the Canadian Human Rights Tribunal (CHRT) found that the Government of Canada’s approach to services for Indigenous children was discriminatory. One way to address this is through a renewed approach to Jordan’s Principle.  

Jordan’s Principle is named in memory of Jordan River Anderson, a young boy from Norway House Cree Nation in Manitoba. He spent his life in a hospital caught in a dispute between the governments of Canada and Manitoba. Both governments refused to pay for the in-home medical care needed for Jordan to live in his home and community.

Jordan’s Principle is not a policy or program. It is a child-first principle that aims to eliminate service inequities and delays for Indigenous children. Jordan’s Principle makes sure all Indigenous children living in Canada can access the products, services and supports they need, when they need them. Funding supports health, social and educational needs, including the unique needs that Indigenous Two-Spirit and LGBTQQIA children and youth and those with disabilities may have.  

Under Jordan’s Principle, the needs of each individual child must be considered to ensure: 

• substantive equality, which means giving extra help when it is needed, so that Indigenous children have an equal chance to thrive as other children in Canada
• culturally appropriate services are provided 
• the best interests of the child are safeguarded

To learn more about Jordan’s Principle, watch the video at this link: https://www.sac-isc.gc.ca/eng/1583694105694/1583694161136 

The Assembly of First Nations has also created a Jordan’s Principle Handbook for First Nations parents, caregivers, families, and communities.

The United Nations Economic Commission for Europe (UNECE) released a policy brief in 2017 on “Older persons in rural and remote areas”. Similar to Canada, many rural areas in Europe see a rapid growth in elder populations. The policy brief proposes several strategies that help seniors to integrate and participate in society and to enhance seniors’ health and well-being:

• Reducing health inequalities by providing older people with better access to health and social care services including emergency care and mental health care
• Joining up transport, housing, health and social care services to improve cost-effectiveness of services and access to services for older people
• Developing cost-effective transport solutions to increase accessibility to services and better social integration
• Improving housing and local environment conditions to allow older people to ‘age in place’
• Developing volunteering and community-based initiatives to improve social integration of older people
• Stimulating bottom-up social enterprises and collaborative ventures to improve the economic diversity and attractiveness of rural areas to encourage in-migration and further economic development.

The policy brief stresses that policies in rural areas need to be flexible and sensitive to local variations in cultural and physical realities. Furthermore, the policies should be designed and implemented at a local level in collaboration with local businesses and seniors, and supported by higher levels of government.

The policy brief showcases some interesting and innovative programs (see example below) that benefit elders in rural areas that might serve as inspiration!

In 2015, the Government of Alberta published a Rural Health Services Review. The purpose of the review was to understand the health-care challenges that rural communities experience and to propose recommendations for improvement.

The Review Committee first set out 11 principles about the rural environment that are important to keep in mind for the review. The principles focused on the need for fair health-care access for all Albertans, to consider each community unique, to listen to local knowledge when defining needs and challenges, and the need to engage local communities in creating solutions.

The Review Committee then met with more than 100 rural communities and 30 health-care organizations to hear their concerns and ideas for solutions. Guided by the 11 principles, they put forward 56 recommendations to deal with major challenges and support future service planning, design, and delivery of health care. In general, the recommendations called for:  

• Greater engagement, decision-making, and responsibility at the community level  
• Use of team-based primary health-care services  
• Improving EMS dispatch and operations  
• Better workforce sustainability with focus on home-grown health-care professionals  
• Better use of existing facilities  
• Acknowledging the important role health-care facilities and services have for the economy of rural communities and the province as a whole 

The full list of recommendations includes sections specific to primary health care, mental health and addictions, continuing care, telehealth, recruitment and retention of health professionals, and infrastructure. Click here to read the full report and all 56 recommendations.

Click on the links below to explore interesting reads about rural health policy.

• Editorial: The Challenge of Rural and Northern Health Systems
• Fact Sheet on Rural Health Care
• Rural Health Policy FAQs from the Rural Health Information Hub