JANUARY

CANADA
funding to 145 not-for-profit hospital corporations (with 224 different facilities and sites) and six private for-profit
hospitals (Ontario Ministry of Health and Long-Term Care, 2014).
Hospitals in Canada generally operate under annual global budgets, negotiated with the provincial or territorial
ministry of health or regional health authority. However, several provinces have considered introducing activitybased
funding for hospitals, including Ontario, Alberta, and British Columbia (Sutherland et al., 2013, 2013a).
Hospital-based physicians generally are not hospital employees and are paid fee-for-service directly.
Mental health care: There is universal coverage for physician-provided mental health care, alongside a
fragmented system of allied services. Hospital mental health care is provided in specialty psychiatric hospitals
and in general hospitals with adult mental health beds. The provinces and territories all provide a range of
community mental health and addiction services including case management, community-based crisis response,
and supported housing (Goering et al., 2000). Psychologists may work privately and are paid out-of-pocket or
through private insurance, or under salary in publicly funded organizations. Mental health has not been formally
integrated into primary care; any coordination or colocation of mental health services within primary care is
unique to its particular practice. In Ontario, the government introduced an intersectoral mental health strategy
in 2011 that aims to better integrate mental health care into primary care (Government of Ontario, 2011).
Long-term care and social supports: Long-term care and end-of-life care provided in nonhospital facilities and
in the community are not considered insured services under the Canada Health Act. All provinces and territories
fund services, but coverage varies among and within them. All provinces provide some nursing home 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, and many
jurisdictions require client contributions (OECD, 2011). About half of the provinces and territories provide some
home care without means-testing, but access may depend both on assessed priority and on availability within
capped budgets (Health Canada, 2013b).
Eligibility criteria for home and institutional long-term care services vary across provinces but generally include
a needs assessment based on health status and functional impairment. Some provinces have established minimum
residency periods as an eligibility condition for facility admission. Spending on nonhospital institutions, of which
the majority are long-term care facilities, accounted for just over 10 percent of total health expenditure in 2013,
with financing mostly from public sources (71%) (Canadian Institute for Health Information, 2015a).
A mix of private for-profit (41%), private not-for-profit (43%), and public facilities (13%) provide long-term care
(Statistics Canada, 2011). Public funding of home care is provided either through provincial or territorial
government contracts with agencies that deliver services (e.g., the Community Care Access Centres, in Ontario)
or through government stipends to patients to purchase their own services (e.g., the “Choice in Support for
Independent Living” program in British Columbia).
Provinces and territories are responsible for delivering palliative and end-of-life care in hospitals, where the
majority of such costs occur. But many provide some coverage for services outside those settings, such as
doctors, nurses, and drug coverage in hospices, in nursing facilities, and at home.
Support for informal caregivers (estimated to provide 66% to 84% of care to the elderly) varies by province and
territory (Grignon and Bernier, 2012). In Ontario, for example, the Family Caregiver Leave Bill offers job
protection to caregivers. There are also some federal programs, including the Family Caregiver Tax Credit and
the Employment Insurance Compassionate Care Benefit (Canada Revenue Agency, 2014; Government of
Canada, 2014).
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The Commonwealth Fund