Canada is the world's second largest country by total area and is made up of 13 provinces and territories stretching from the Atlantic Ocean in the east to the Pacific Ocean in the West and bounded north and south by the Arctic Ocean and USA land border respectively.

Each province and territory has its own government and Ministry of Health which is responsible for the funding and administration of the healthcare system within its jurisdiction, supported by the federal government on a per capita basis. The healthcare system is therefore universal and publicly funded on a national basis, yet locally decentralised with considerable variations in benefits, access and delivery approaches.

All Canadian citizens and permanent residents are entitled to receive medically necessary hospital and physician services free of charge at the point of delivery. However some medical services are excluded. Outpatient prescription drugs and dental care are general exclusions, although provinces and territories provide some coverage for targeted groups. 67% of Canadians have private medical insurance.

Universal Healthcare - Canadian Medicare

Canada’s universal, publicly funded health care system, called Canadian Medicare, was established through federal legislation originally passed in 1957 and in 1966. The Canada Health Act of 1984 replaced and consolidated the two previous acts and set national standards for medically necessary hospital, diagnostic, and physician services.

Each provincial and territorial government must operate its own health insurance plan which needs to comply with the five pillars of the Canada Health Act 1984 in order to secure eligibility for full federal cash contributions. The health insurance plan must be:

1. Publicly administered
2. Comprehensive in coverage conditions
3. Universal
4. Portable across provinces
5. Accessible (for example, without user fees).

The Role of Provincial and Territorial Governments

Canadian Provincial and Territorial Governments have primary responsibility for financing, organizing, and delivering health services and supervising providers.

The jurisdictions directly fund physicians and drug programs, and contract with delegated health authorities (either a single provincial authority or multiple subprovincial, regional authorities) to deliver hospital, community, and long-term care, as well as psychiatric care and public health services.

Most physicians and healthcare professionals are self-governing under provincial and territorial law and are registered with a provincial medical regulatory authority (such as the College of Physicians and Surgeons) which ensures that education, training, and quality-of-care standards are met.

Most provinces have an ombudsperson who advocates on behalf of patients.

The Role of Federal Government

The federal government co finances provincial and territorial universal health insurance programs and administers a range of services for certain target populations:

• eligible First Nations and Inuit peoples
• members of the Canadian Armed Forces
• veterans of the Canadian Armed Forces
• resettled refugees and some refugee claimants
• inmates in federal penitentiaries.

The federal government also regulates the safety and efficacy of medical devices, pharmaceuticals, and natural health products, funds health research and some information technology systems, and administers several public health functions on a national scale.

At the national level, a variety of governmental agencies oversee specific functions:

Health Canada:

Health Canada is the federal ministry of health and it is responsible for:

• upholding of national standards for universal health coverage.
• regulating food and drug safety, medical device and technology review
  

The Public Health Agency of Canada

The Public Health Agency of Canada is responsible for public health, emergency preparedness and response, infectious and chronic disease control and prevention, and health promotion.

Indigenous Services Canada

Indigenous Services Canada is a new federal government department funds certain health services for the First Nations and Inuit populations.

The Role of Public Health Insurance

The World Bank estimated that health spending reached 10.84 % of Canada's GDP in 2019, with a steady increase since 2000 when it was just 8.25%. The public sector accounts for 707% of total health expenditure with the balance of 30% made up by the private sector.

The main funding source is general provincial and territorial government revenue, largely derived from taxation. The balance (around 24% of total funding) is provided by the federal government under the Canada Health Transfer program.

Each provincial and territorial health insurance plan covers all medically necessary hospital and physician services (on a prepaid basis). Supplementary services, or those not covered under Canadian Medicare, are largely privately financed, either from patient out-of-pocket payments or through employer-based or private insurance.

Provinces and territories cover all of their own residents in accordance with their respective residency requirements.

Temporary legal visitors, undocumented immigrants, visitors who stay in Canada beyond the duration of a legal permit, and those who enter the country illegally are not covered by any federal, provincial or territorial  program. Provinces and territories provide limited emergency services to these non eligible populations. No physician or hospital can refuse to provide care in an emergency, and midwives provide some maternity services.

The Role of Private Health Insurance

Private healthcare insurance, held by about two-thirds of Canadians, covers services excluded under universal health coverage, typically optical and dental care, outpatient prescription drugs, rehabilitation services, and private hospital rooms.

Approximately 90 percent of premiums for private health plans are paid through employers, unions, or other organizations under a group contract or uninsured contract (by which a plan sponsor provides benefits to a group outside of an insurance contract).

Services Covered by Canadian Medicare

To qualify for federal financial contributions,  provincial and territorial health insurance plans must provide coverage of medically necessary physician, diagnostic, and hospital services (including inpatient prescription drugs) for all eligible residents.

All provincial and territorial governments also provide public health and prevention services (including immunisations) as part of their public programs.

However, aside from the essentials, there is no nationally defined statutory benefit package and most public coverage decisions are made by provincial and territorial governments in conjunction with the medical profession. Healthcare coverage therefore varies across the provinces and territories of Canada for the services which are not federally mandated as medically necessary. This includes outpatient prescription drugs, psychiatry and psychology services, optical services, dental care, home care, midwifery services, medical equipment, and hospice care.

Most provinces have public prescription drug coverage programs for specific populations, such as recipients of social assistance, seniors aged 65 and older, and children and adolescents. Some programs charge premiums, often income-related.

There are some health services that, for the most part, are not covered by any provincial and territorial insurance plan, including dental services, physiotherapy, psychologist visits, chiropractic care, and cosmetic or plastic surgery.

Cost-sharing and Out-of-Pocket Spending

There is no cost-sharing for publicly insured physician, diagnostic, and hospital services. Physicians are not allowed to charge patients prices above the negotiated fee schedule.

The majority of out-of-pocket payments are spent on nonhospital institutions (mainly long-term care homes), prescription drugs, dental care, and vision care.

Safety Nets

Most provinces and territories provide outpatient drug plans to some individuals lacking private employer-sponsored insurance. Most of these outpatient drug plans operate as payers of last resort, targeting people on social assistance or of retirement age and vary considerably. For instance, Quebec administers a universal drug plan by mandating that eligible individuals have private coverage and enrolls those not eligible for private coverage in the public plan. In contrast, Ontario, Canada’s most populous province, administers a universal prescription drug program for seniors, children and adolescents without private coverage, and recipients of social assistance.

Provincial and territorial governments also provide some relief for people with high out-of-pocket expenses. After citizens pay more than 3 percent of their net income for eligible medical expenses per year, they can receive a 15 percent tax credit for any remaining expenses.

In addition, provinces and territories pay for accommodation and food expenses (beyond nursing care) of indigent individuals in publicly financed long-term care facilities.

How is Medical Care Delivered and Paid for?

Physicians

Here are some basic facts about physicians practicing in Canada.

• 17 public medical schools in Canada
• 27% of Canada's practicing physicians are international medical graduates
• 92% of physicians practise in urban locations
• 2.3 practicing physicians per 1,000 population
• Just over 50% of physicians (1.2 per 1,000 population) are family physicians, or general practitioners (GPs)
• Just under 50% of physicians (1.15 per 1,000 population) are specialists
• Most physicians are self-employed in private practices.
• In most provinces, specialists have the same fee schedule as primary care physicians.
• There is a physician shortage in rural and remote locations but there are no national programs to ensure a supply of doctors to these locations. However, most provinces have rural practice initiatives. For example, Alberta’s Rural, Remote, Northern Program guarantees physicians an income greater than CAD 50,000 (USD 39,382).

Provincial ministries of health negotiate physician fee schedules (for primary and specialist care) with medical associations. In some provinces, such as British Columbia and Ontario, payment incentives have been linked to performance.

The majority of physicians and specialists bill provincial and territorial governments directly, although some are paid a salary by a hospital or facility. Patients may be required to pay out-of-pocket for services that are not covered by public insurance plans.

Specialists

Specialists are mostly self-employed in their own practices. There are few formal multispecialty clinics.

The majority of specialist care is provided in hospitals, on both an inpatient and an outpatient basis, although there is a trend toward providing less-complex services in nonhospital diagnostic or surgical facilities.

Specialists are paid on a fee-for-service basis, although there is variation across provinces and some provinces offer salaried contracts of employment which have retention and sometimes sign up bonuses.

Patients can choose to go directly to a specialist, but it is more common for GPs to refer patients to specialty care. Specialists who bill provincial and territorial public insurance plans are not permitted to receive payment from privately insured patients for services that would be covered under public insurance.

General Practitioners - Family Physicians

• GPs act largely as gatekeepers, and many provinces pay lower fees to specialists for non-referred consultations.
• 46 percent of GPs work in a group practice, 19 percent in an interprofessional practice, and 15 percent in a solo practice. There are some salaried GP jobs.
• In several provinces, networks of GPs work together and share resources, with variations across provinces in the composition and size of teams.
• In theory, patients have free choice of a GP; in practice, however, patients may not be accepted into a physician’s practice if the physician has a closed list.
• The requirements for patient registration vary considerably by province and territory, but no jurisdiction has implemented strict rostering. Quebec, through Family Medicine Groups, has used patient enrollment and added (human and financial) resources to improve access to care.
• Fee-for-service is the primary form of physician payment, although there has been a movement toward alternative forms of payment, such as capitation and salaries.
• Historically, GPs have not been required to provide after-hours care, although newer group-practice arrangements stipulate requirements or financial incentives for providing after-hours care to registered patients.
• After-hours care is often provided in physician-led walk-in clinics and hospital emergency rooms. In most provinces and territories, a free telephone service allows citizens to get health advice from a registered nurse 24 hours a day.
  

Registered Nurses

• 62 percent of regulated nurses (registered nurses, nurse practitioners, and licensed practical nurses) work in hospitals and 15 percent in community health settings on salaries.
• In the three northern territories (Yukon, Northwest Territories, and Nunavut), primary care is often nurse-led.

Hospitals

Hospitals are a mix of public and private, predominantly not-for-profit, organizations. They are often managed by delegated health authorities or hospital boards representing the community. In most provinces and territories, many hospitals are publicly owned, whereas in Ontario they are predominantly private not-for-profit corporations.

Hospitals in Canada generally operate under annual global budgets, negotiated with the provincial ministry of health or delegated health authority. However, several provinces, including Ontario, Alberta, and British Columbia, have considered introducing activity-based funding for hospitals, paying a fixed amount for some services provided to patients.

Hospital-based physicians generally are not hospital employees and are paid fee-for-service directly by the provincial ministries of health.

Psychiatric and Mental Health Care

Physician-provided mental health care is covered under Canadian Medicare, in addition to a fragmented system of allied services. Hospital-based mental health care is provided in specialty psychiatric hospitals and in general hospitals with mental health beds.

The provincial and territorial governments all provide a range of community mental health and addiction services, including case management, help for families and caregivers, community-based crisis services, and supportive housing.

Private psychologists are paid out-of-pocket or through private insurance. Psychologists who work in publicly funded organizations receive a salary.

Mental health has not been formally integrated into primary care. However, some organizations and provinces have launched efforts to coordinate or collocate mental health services with primary care.

Long-term Care and Social Supports

Long-term care and end-of-life care provided in nonhospital facilities and in the community is not considered to be an insured service under the Canada Health Act. However all provincial and territorial governments fund such services through general taxation, but coverage varies across jurisdictions.

All provinces provide some residential care and some combination of case management and nursing care for home care clients, but there is considerable variation when it comes to other services, including medical equipment, supplies, and home support. Many jurisdictions require copayments.

Eligibility for home and residential long-term care services is generally determined via a needs assessment based on health status and functional impairment. Some jurisdictions also include means-testing. About half of provincial and territorial governments provide some home care without means-testing, but access may depend both on assessed priority and on the availability of services within capped budgets.

The government funds personal and nursing care in residential long-term facilities. In addition, financial supplements based on ability to pay can help support room-and-board costs. Some provinces have established minimum residency periods as an eligibility condition for facility admission.

Spending on nonhospital institutions, most of which are residential long-term care facilities, is estimated to account for just over 10% of total health expenditures with 70% of financing from public sources. A roughly equal mix of private for-profit, private nonprofit, and public facilities provide facility-based long-term care.

Public funding of home care is provided either through provincial and territorial government contracts with agencies that deliver services or through government stipends to patients to purchase their own services.

Provinces and territories are responsible for delivering palliative and end-of-life care in hospitals (covered under Canadian Medicare), where the majority of such costs occur. But many provide some coverage for services outside those settings, such as physician and nursing services and drug coverage in hospices, in nursing facilities, and at home.

Accessing Public Health Insurance

If you are a Canadian citizen or permanent resident, you are eligible to apply for a health card from your province or territory to enable you to access health care. You must show the card to the physician or medical professional who attends you. However In some provinces, you may be waiting up to 3 months for your public health insurance to start so you will need to ensure that you have adequate private health insurance to cover your health care needs during this waiting period.

If you do not have Canadian citizenship or permanent residency, you will need to purchase private health insurance to cover your full healthcare needs.

Provincial and Territorial Ministries of Health

• Alberta
• British Columbia
• Manitoba
• New Brunswick
• Newfoundland and Labrador
• Northwest Territories
• Nova Scotia
• Nunavut
• Ontario
• Prince Edward Island
• Quebec (in French only)
• Saskatchewan
• Yukon

Physician and Medical Jobs in Canada

Doctors interested in working in Canada as a specialist or family physician and eligible for a licence to practise with one or more of the 13 provincial and territorial Colleges of Physicians and Surgeons are invited to register a CV and contact us to discuss opportunities. Advertised jobs can be viewed on our website and applications made by uploading a recent CV which addresses the eligibility criteria as set out in the job advert.

The following articles provide detailed guidance on professional registration in Canada, the MCCQE 1 examination, obtaining jobs and registration as a specialist physician, family physician jobs and for those seeking immediate permanent residency status, the Atlantic Immigration Project.