Equity in access and use of rehabilitation services in Canada
Two Canadians, equal under the law. Only one gets rehabilitation services. What gives?
By Nivetha Chandran, rehabinkmag February 4, 2021
To answer this question, we must start by understanding what the Canadian healthcare system is set up to do and why it is not working for all Canadians. The COVID-19 pandemic has highlighted how difficult it can be to access health services, including rehabilitation. Although, the responses to resuming health services post-lockdown have been creative, specifically in rehabilitation, this pandemic has sparked critical discussions around health equity.[1,2]
Only two out of three Canadians have private insurance which covers some or all of their rehabilitation expenses, indicating inequitable access to rehabilitation services. This commentary discusses current barriers and offers potential solutions to creating equitable rehabilitation access to rehabilitation services in Canada.
The World Health Organization defines rehabilitation as interventions that aim to optimize and reduce disability in individuals with health conditions as they interact with their environment. Rehabilitation encompasses a wide range of services for people living with injuries, chronic conditions, and episodic disabilities available in hospitals, clinics, and in the community.
In 2017, around 22% of Canadians (6.2 million) ages 15 and above identified living with one or more disabilities. Canada, like other nations, has a growing aging population, a rise in people living with chronic illness and episodic disabilities, and growing healthcare costs.[6-8] Together, this indicates a rapidly diverse population with correspondingly diverse healthcare needs. These changes in Canada’s population and utilization of the healthcare system indicate the growing need for rehabilitation services in Canada.
|Accessible Healthcare is Meant For All Canadians|
Canada has a decentralized, universal, and publicly funded healthcare system. The healthcare system is based on the Canada Health Act, which encompasses five principles: public administration, comprehensiveness, universality, portability, and accessibility of “medically necessary services” for Canadians across all provinces and territories. Accessibility means availability of insured health services without charge or paying for user fees, and is supposedly a pillar of the Canadian healthcare system, one principles intended to provide Canadians with quality and effective healthcare. In theory, the Canada Health Act appears to ensure that Canadians have quality and effective healthcare. However, this is not the case in practice due to the differences in how medically necessary services are defined.
The definition of medically necessary services  is determined by each province and territory. Hence, provinces and territories are in control of administering and delivering health services for individuals in their respective jurisdictions. Unfortunately, this leads to different services (e.g., outpatient prescriptions, dental care, eye care) including rehabilitation services to be funded by private insurance and out-of-pocket payments for adults over age 18. Therefore, a significant portion of the population is unable to access necessary healthcare services, which creates health disparities. Health disparities are magnified as people having full-time jobs with private insurance can better access healthcare than individuals without job security, those with less education, and lower socioeconomic status.
Unfortunately, these people are less likely to access these services despite the fact that they are likely the people that most need care.
Addressing barriers in each service area can bridge the existing access gap and reduce health disparities experienced by people who cannot access healthcare services not defined as medically necessary. The following barriers affecting accessibility of rehabilitation services can be reduced and ultimately eliminated if possible.
|Barriers and Solutions in Accessing and Using Rehabilitation Services in Canada|
Let’s understand how two Canadians might access rehabilitation services given the barriers in healthcare cost, availability, and education/awareness.
|Sophia lives in Northern Ontario and is unable to access all types of health services due to living in a remote community and her seasonal job in the fishing industry. Unfortunately, due to a recent injury to her back, she needs access to a physiotherapist but cannot, due to the cost. Furthermore, she does not have an insurance plan due to her seasonal work and is not sure how to obtain access to rehabilitation services.|
|Ben works as a financial advisor for one of the largest banks in Toronto. He had to recently been diagnosed with an anxiety disorder and has been able to access a psychologist for weekly therapy sessions due to his work benefits. He was aware of the services as it was listed in his employee guide and he had better knowledge due to the abundance of services in Toronto to help manage anxiety.|
The financial aspect of accessibility to rehabilitation services is a key area to address for equitable access and use of rehabilitation services. Some people are insured for out-of-pocket healthcare expenses through their employment. However, for people living with chronic and episodic illnesses, securing stable employment could be difficult.
Therefore, people have to use a provincial support program such as the Ontario Disability Support Program and will be unable to work due to its eligibility criteria.[11,12] There are many jobs in Canada that do not offer employee benefits, such as those where the individual is self-employed, a seasonal worker or part time or casual worker.
When we consider the factor of cost within Sophia and Ben’s stories, we can see that Ben is able to access the necessary services due to his ability to pay with work benefits, while Sophia is unable to do so, since she is not covered with an insurance plan. There is not one solution to address the barrier of cost, but a comprehensive approach to reducing this barrier is likely the only strategy to make the change effective.
One area to consider is creating change on the policy level in both provincial and territorial governments. Policies which ensure people have some access to insurance through employment can reduce the gap in access. Furthermore, eligibility criteria for government plans such as Ontario Disability Support Program could be more inclusive of those that have a job, without reduction in benefits from the program.
|Availability of Services|
Although there has been an increase in the number of physiotherapists and occupational therapists in Canada, it has not kept up to the increase in the Canadian population. Due to this lack of availability, long wait times can exacerbate people’s health condition and lead to more burden on the healthcare system.
Remote and rural communities are at a further disadvantage because of the inequitable distribution of rehabilitation professionals across Canada, who tend to practice in urban centres. Sophia is unable to access a physiotherapist as the only publicly funded physiotherapy clinic is over an hour drive and there is a 6-month waitlist. However, Ben was able to access a private practice psychologist as he did not need to navigate which services were available as an Ontario resident, and he lived in Toronto, an urban centre.
One method of increasing accessibility in underserved communities is the creation of incentivized programs that station healthcare professionals in underserved regions. The uses of technology and tele-rehabilitation can further reduce these service gaps by increasing access to rehabilitation health professionals.
|Education and Awareness|
Rehabilitation services may be under utilized due to a lack of awareness by the general population. This lack of awareness causes people not to access services they are able to use meaning they may be unaware of the benefits of using rehabilitation services.
Due to Ben’s work benefits and employee guide, he was aware of the services and able to access a psychologist. But Sophia is unaware of what else to do after her doctor prescribed her pain medication and referred her to physiotherapy because the closest publicly funded clinic is over an hour drive and there is a 6-month waitlist.
One suggestion to address this issue is the creation of multidisciplinary teams in primary care to address rehab services because it brings awareness to the diverse scope of practices of health professionals including rehabilitation professionals such as physiotherapists and occupational therapists. To bring awareness and direct people to rehabilitation services, a directory can also be established of rehabilitation services from a provincial and territorial level.
Through addressing the barriers of cost, availability of services, and education and awareness ― Canadians can lead healthier lives. This article continues the conversation COVID-19 started about equitable access to rehabilitation services in Canada. Now is the time to make these provincial and national changes so that all Canadians, equal under the law, may have equitable access to the rehabilitation services they need.
|Featured illustration by Abeeshan Selvabaskaran for rehabINK.|
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