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The geographies of crisis: exploring accessibility to health care in Canada.

Article Excerpt
De plus en plus de Canadiens s'inquietent que leur systeme de soins de sante soit en etat de crise. On defend l'idee selon laquelle la reduction des paiements de transfert aux provinces par le gouvernement federal serait responsable de l'etat d'un systeme de sante caracterise par un sous-financement dans les domaines-cles et des decisions politiques de sante basees, non pas sur les besoins des membres de la societe canadienne, mais sur la fiscalite provinciale. Les gouvernements provinciaux ont reagi a la reduction du financement federal par une tactique de restructuration agressive (fermeture d'hopitaux et retrait de services medicaux des programmes d'assurance de sante provinciaux). Selon les medias, les groupes de consommateurs et meme les chercheurs en soins de sante, cette restructuration a eu pour effet un systeme en etat de `crise' (diminution de l'acces aux services, longues listes d'attente, hopitaux surcharges, augmentation des couts des medicaments etc). Un des themes recurrent est celui des decisions fiscales de toutes sortes qui entrainent une baisse de l'accessibilite financiere et geographique. Cette accessibilite est pourtant un des cinq principes de la Loi canadienne sur la sante definissant l'essence meme du systeme de sante au Canada. Utilisant les donnees tirees de l'Enquete nationale sur la sante de la population, 1998-99 et examinant l'acces aux services de sante et les obstacles rencontres dans les 10 provinces canadiennes, cet article evalue dans quelle mesure une crise d'accessibilite existe au sein du systeme de sante canadien. Les resultats demontrent qu'environ 6.0 pour cent des Canadiens ont rencontre des problemes d'accessibilite, avec des variantes allant de 4.5 pour cent a Terre-Neuve jusqu'a 8.3 pour cent au Manitoba. On observe aussi des variantes regionales dans les obstacles rencontres. L'accessbilite geographique en particulier semble un obstacle majeur dans les regions de l'Atlantique, alors que l'accessibilite financiere semble etre un obstacle majeur dans l'Ouest du Canada. Ces resultats sont presentes dans le contexte des debats actuels sur l'existence d'une `crise' dans le systeme de sante au Canada.

Mots-cles: Soins de sante, accessibilite, geographies de la crise

Introduction

Human geographers have long been concerned with issues of geographic accessibility. In health geography, access to health care services has consistently been identified as a key theme of research (Mayer 1982; Meade et al. 1988; Rosenberg 1998; Meade and Earickson 2000). Within Canada, accessibility takes on special meaning for geographers in general, health geographers in particular and most critically to all Canadians because of the fifth principle of the 1984 Canada Health Act (CHA).

The CHA is the only piece of Federal legislation that governs health care delivery in the provinces and territories. According to the CHA, all provinces and territories in Canada must abide by five principles in order to receive federal funds: universality; comprehensiveness; portability; public administration; and accessibility. The underlying sentiment of `accessibility' in the CHA is to ensure access to medically necessary health care services for all Canadians regardless of ability to pay. In fact, the act states that to meet the requirements of accessibility, provincial health insurance plans "must provide for insured health services on uniform terms and conditions and on a basis that does not impede or preclude, either directly or indirectly whether by charges made to insured persons or otherwise, reasonable access to those services by insured persons."

Some researchers have argued that the CHA is unclear in its discussion of what constitutes `reasonable access' to medically necessary services (e.g., Eyles et al. 1995). However, recently, Health Canada has distinguished between two types of reasonable access--economic and physical (Health Canada 2000). According to Health Canada, economic accessibility refers to the provision of health care services without financial charges, either direct or indirect. Physical access, on the other hand, is "interpreted under the Canada Health Act using the "where and as available" rule. Thus, residents of a province or territory are entitled to have access to insured health care services at the setting "where" the services are provided and "as" the services are available in that setting;" (Health Canada 2000, 7).

The provinces and the territories have interpreted the latter part of the accessibility principle to mean that they have a responsibility to provide health services in large cities and small towns, rural areas and remote areas. They do so through various mechanisms ranging from incentives for physicians to locate in underserviced areas to telemedicine to programs that subsidize the costs of patients who need to travel to specialized medical facilities found only in the largest cities or even outside of Canada.

Access to health care services is, therefore, an important issue for geographers to consider given its importance in the CHA and the importance that Canada's public, universal and comprehensive health care systems holds in the Canadian psyche. Access to health care services is also an especially salient issue to explore given the current political and social climate in which the future of the health care system in Canada is being debated.

Throughout the 1990s and into the present decade, there is increasing concern that the Canadian health care system is in a state of crisis. One crisis theme often mentioned is that fiscal decisions of various kinds are reducing accessibility as defined by the CHA. While there is much anecdotal evidence of the existence of a crisis, there are few systematic studies to assess whether a crisis exists and what type of crisis is it. Given this gap in our knowledge, using data from the National Population Health Survey (NPHS), this paper explores the extent to which an accessibility crisis exists within the Canadian health care system by examining access to health care services and the barriers encountered in trying to access services in each of the ten provinces.

The next section of this paper sets the context for the analysis to follow by first discussing the rhetoric of crisis as presented in the media and various health reports and second by outlining the framework we employ for examining accessibility to health care services. The third section describes the NPHS data set and the statistical methods employed in this analysis. In the fourth section, we discuss the main research findings that demonstrate most Canadians continue to indicate that their access to health care services in Canada is good. The results also reveal regional variations in barriers to accessing care. In particular, geographic accessibility appears to be a major barrier to care in Atlantic Canada while economic accessibility emerges as a main barrier to care in Western Canada. The final section of the paper situates the findings in the context of the current debates on the Canadian health care system `crisis'.

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