Under the Constitution Act, 1867,
health care is not assigned exclusively to one level of government, but rather
includes matters that could fall within both federal and provincial
jurisdictions. The
Constitution grants the provinces primary jurisdiction in the area of HHR.
Section 92(13), the power over “property and civil rights in the province”,
which covers contract, tort and property, is the main provincial power over
health care. It
authorizes provinces to regulate businesses in the province, including the
public and private provision of health care insurance, which determines the
payment schemes for services offered by health care providers. More
significantly, it also provides for the provincial regulation of health care providers.
Section 92(7) grants the provinces authority to establish and regulate
hospitals, as well as hospital-based health services, with the exclusion of
marine hospitals.
However, section 91 of the Constitution
Act, 1867, also grants the federal government authority over some classes
of people including: military, militia, and naval services; First Nations and
Inuit; and federal inmates. Under section 95, the federal government also has
jurisdiction over immigrants concurrently with the provinces. It is important to
note that how the federal government exercises its jurisdiction over these
groups in relation to health care delivery and health human resources varies
substantially by federal client group. The federal role in HHR for each of
these respective population groups is examined in greater detail in Chapter 7. Furthermore,
as the employer of the federal public service, the federal government is
responsible for the occupational health and safety of its employees, as well as
any employment-related health benefits provided to federal public service
workers.
In addition, under the Canada Health Act ,
the federal government has used its spending power to establish national
standards for the provinces’ health care insurance plans as a condition of
federal cash contributions to these programs. The federal spending power is not
specifically identified in the constitution, but rather is inferred from
Parliament’s jurisdiction over public debt and property (section 91(1A)) and
its general taxing power (section 91(3)), and has been upheld through court
decisions. In
using its spending power, the federal government may establish conditions for
federal grants to the provinces, including conditions that come within
provincial jurisdiction and therefore cannot be directly legislated by
Parliament.
Under the Canada Health Act, the
federal government has established the following national standards for
provincial and territorial health care insurance plans: (1) public
administration; (2) comprehensiveness; (3) universality; (4) portability: and
(5) accessibility. With respect to HHR, it is important to note that section 9 of the Canada
Health Act dealing with comprehensiveness stipulates that the health care
insurance plan of a province “must insure all insured health services provided
by hospitals, medical practitioners or
dentists, and where the law of a province so permits, similar or additional
services rendered by other health care practitioners.” This means that the Canada Health Act requires that physicians services
be covered by a provincial health care insurance plan, but does not require
that provincial plans cover the costs of services provided by other health
professionals that are also the subject of this report, such as: pharmacists,
physiotherapists, chiropractors, psychologists, naturopathic doctors, and other
non-physicians.
Despite this separation of powers, the
federal government has a long history of collaboration with the provinces and
territories in both health and health care. This was manifested in the 2003
Accord on Health Care Renewal, where federal, provincial and territorial
(F/P/T) governments recognized the need to collaborate across jurisdictions to
address HHR challenges across the country. However, they also agreed that this
would be done in a fashion that would fully respect each government’s
jurisdiction. In
the Accord, they agreed to collaborate in HHR planning in order “to strengthen
the evidence base for national planning, promote inter-disciplinary provider
education, improve recruitment and retention, and ensure the supply of needed
health providers.” To
this end, the federal government committed $85 million to HHR renewal, as well
as ongoing funding of $20 million per year to develop a pan-Canadian HHR
strategy.
These commitments were further elaborated
upon in the 2004 F/P/T 10-Year Plan to Strengthen Health Care, which was based
upon several principles including, among others: collaboration between all
governments, advancement through the sharing of best practices, and
jurisdictional flexibility. The
agreement also took into account the principle of asymmetric federalism,
allowing for the existence of a separate agreement for any province, including
the Government of Quebec, which signed a separate Communiqué with the federal
government regarding the interpretation and implementation of the 10-Year Plan.
With respect to HHR, governments further
agreed to increase the supply of health professionals by establishing action
plans that would include targets for training, recruitment and retention of
professionals. To
achieve these objectives, First Ministers committed an additional $5.5 billion
over 10 years to reduce wait times, which would include ongoing collaborative
work in HHR. The
federal government further committed to:
- Accelerate and expand the assessment and integration of
internationally trained health care graduates for participating governments;
- Target efforts in support of Aboriginal communities and official
language minority communities to increase the supply of health care professionals
for these communities;
- Take measures to reduce the financial burden on students in
specific health education programs; and
- Participate in HHR planning with interested jurisdictions.
Specific details regarding the federal
government’s particular investments and programs and initiatives related to
these commitments are the subject of subsequent chapters in this report.
Finally, it is important to note that the
House of Commons Standing Committee on Health was also granted authority to
review progress towards the implementation of the 10‑Year Plan to
Strengthen Health Care under section 25.9(1) of the Federal-Provincial
Fiscal Arrangements Act, which authorized the transfer of federal funds to
the provinces in support of the plan.