The Two Tier Medicine in Canada: Urban versus Rural
“Waiting times mean little, when there is nothing to wait for.” (Nagarajan, 2004)
Introduction “If there is a two tier medicine in Canada it is not rich and poor, it is urban versus
rural” (Nagarajan, 2004a). This were the words of Dr. John Wooton, Special Advisor on RuralHealth to Health Canada when describing the circumstances facing rural Canadians with respect to access to healthcare. Incredibly enough, this words were not pronounced last year, or the year before. These words reached the ears of government agencies over ten years ago, however nothing has really changed in the last decade. The Canada Health Act (CHA) is clear on its principles of universality,accessibility and portability, however very little to none of these are true for rural areas. The decision to close rural health centers by several provincial governments in the most recent years, has contributed to worsen the health conditions for rural Canada. The differences are so evident that the chasm between rural and urban The disparities that rural Canadians are forced to endure in
becomesgreater with time.
accessing of medical services, is not only socially unjust, but it is also a violation of their constitutional rights.
II. Historical Background The Canada Health Act establishes as the primary objective of the Canadian healthcare policy to “protect, promote and restore the physical and mental well being of residents of Canada and to facilitate reasonable access to healthservices without ﬁnancial or other barriers.” (CHA, 1985). To do so, it outlines ﬁve principles that summarize the essence of the
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act: Public administration, comprehensiveness, universality, portability and accessibility. The ﬁrst two refer to proﬁt and coverage. The universality principle guarantees that every person covered by thesystem is covered in the same manner and under the same terms. Portability guarantees mobility rights of those insured by covering their healthcare needs wherever they might be (inside or outside Canada). And ﬁnally, the accessibility principle promises no ﬁnancial barriers to accessing healthcare services.
In 1991, 29.2% of Canadians lived in rural areas and 14.9% of all physicians practicedin those areas, as reported by the Canadian Medical Association Journal (CMAJ) in 1992. At the time, the imminent shortage of physicians in rural areas was already deﬁned, the causes for such shortage were identiﬁed, and the retention factors were outlined. This report provided a “framework for understanding these factors” (Rourke,1993) and included suggestions on how cooperation between alllevels of healthcare could address the situation and prevent further deterioration of the rural healthcare system and facilitate the process in each province.
In 1996, 22.2% of Canadians still lived in rural areas, and 9.8% of all Canadian physicians practiced there. Statistics were already showing a steady decrease both in population and medical service providers, much like what the CMAJ hadreported in 1993. However, there were no plans of action devised by the government, regardless of the evidence. The decline in percentage of rural physicians occurred at a faster rate than that of rural population. According to statistical projections, “the ratio of physicians per 1,000 population in rural areas is expected to decrease from 0.79 in 1999 to 0.53 by 2021”, (Hutten-Czapski, 2001a).
In2002, the ﬁnal report of the Romanow Commission on the Future of Health Care in Canada was released. Four recommendations were made by the Romanow report: First, that a Canadian Health Covenant be written, expressing “Canadian’s collective vision for
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healthcare” (Browne, 2004), and outlining the responsibilities and entitlements of...