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PRB 00-20E
THE FEDERAL ROLE
IN RURAL HEALTH
Prepared by:
Nancy Miller Chenier
Political and Social Affairs Division
12 October 2000
TABLE OF CONTENTS
THE
CONTEXT OF RURAL HEALTH
CURRENT FEDERAL ATTENTION
TO RURAL HEALTH
A. Key
Federal Departments Organizing for Rural Health
B. Parliamentary
Initiatives on Rural Health
DOMINANT
IDEAS INFLUENCING FEDERAL ACTION
IN RURAL HEALTH
A. Constitutional Authority
B. Health Approaches
C. Funding Distribution
D. Access to Professionals
and Facilities
E. Research
CONCLUDING OBSERVATIONS
THE FEDERAL ROLE
IN RURAL HEALTH
"The
health of rural people is inextricably bound up with the health of rural
communities."(1)
This paper looks briefly
at how Canada defines its rural population and why people in rural communities
might experience particular health outcomes. It then examines the current
federal government’s efforts to address rural health issues and discusses
selected variables that influence the extent of future federal involvement
and ability to act on rural health concerns.
THE
CONTEXT OF RURAL HEALTH
A significant part of Canada
is rural. When population density and geographical location are considered,
rural Canada comprises approximately 31% of the population and 95% of
the territory.(2) This rural population encompasses people with divergent
needs related to age, gender, socio-economic status, occupation and ethnicity,
while this geographical space embraces diverse terrain and a mixture of
economic activities across resource, manufacturing and service industries.
The 1998 Rural Dialogue
Notebook, prepared by the federal government for public consultation,
observed differences in rural Canada regarding the people and where they
live. It stated that "rural Canada includes rural and remote
communities and small towns outside major urban centres, whether in the
far North or close to major metropolitan cities."(3)
It pointed out that, in Atlantic Canada, almost half of the population
lived in rural areas and this included a majority of the region’s
Acadian and African-Canadian communities. Also, it noted that across Canada,
more than half of the Aboriginal peoples (whether on reserves or in Inuit
or Métis communities) lived in rural areas. Other sources pointed out
that rural populations continue to decline, particularly as young people
leave for educational and employment opportunities and seniors leave to
seek greater access to long-term care. At the same time, rural populations
in closer proximity to cities or in recreational areas are increasing.(4)
Thus, rural Canada is comprised
of many different communities, with diverse languages, cultures, environments,
landscapes and economies. Each community in turn faces different challenges
in meeting the multiple needs of its population. This variety across people
and space makes it difficult to take a single national approach to rural
health.
Although approaches to health
have never been uni-dimensional or static, the more common viewpoint has
been through narrower biological or medical interpretations rather than
through broader social, economic, cultural or political contexts. However,
Canada’s federal, provincial and territorial governments, recognizing
that health cannot be achieved solely by the provision of medical services,
have moved toward broader approaches.(5)
They have taken steps to embrace a population health approach emphasizing
that any strategy to influence the health status of a population must
address a broad range of health determinants. These determinants include:
income and social status, social support networks, education, employment
and working conditions, social environments, physical environments, personal
health practices and coping skills, healthy child development, biology
and genetic endowment, health services, gender and culture.(6)
It is not difficult to see
where geography and rural location might fit as an issue that cuts across
several of these determinants. The Rural Dialogue Notebook indicated
that "National figures show that rural areas are different than urban
areas: for example, rural areas have generally higher unemployment rates;
formal education levels are lower; and, in many communities, more people
are leaving than moving in."(7)
More specifically on health,
the federal Office of Rural Health noted that:
Rural
realities and health needs differ from those of urban areas. These needs
may be particular to the environment (e.g., the need for education on
tractor roll-over prevention), changing demographics (e.g., an increase
in the seniors’ population in some rural areas), a common health
need present in a rural environment (e.g., the health status of First
Nations’ communities), or the need for health concerns to be expressed
in a ‘rurally sensitive’ way (e.g., obstetrical services that
do not generate an excessive ‘travel burden’ on rural women).(8)
The particular health reality
of people living in rural areas can differ not only from their urban counterparts
but also from other rural situations. For example, it is suggested that
"the average rural Canadian lives 10 kilometres from the nearest
doctor" but "the further north you are, the further away the
closest physician is."(9) On other
perspectives such as employment related to seasonal economies, rural people
living in the Prairie provinces have a much lower unemployment rate than
do people living in the Atlantic provinces.
The report of the October
1999 Rural Health Research Summit in British Columbia, provided a broad
perspective, stating that:
Those
who live in rural Canada know instinctively that their health is compromised,
life expectancy is shorter, health care is less accessible, and comprehensive
and continuing care is not a realistic expectation. Death rates and
infant mortality rates are higher, but so are fertility rates, creating
a demographic of young children and older adults associated with a loss
of young adults to the urban opportunities. Communities too can be fragile
while others have acquired a resilience that is hard to ignore.(10)
As this contextual overview
suggests, rural Canada comprises a significant proportion of this country’s
population and territory. The diversity of the people and the geography
pose particular challenges for individual provincial and territorial governments
responsible for providing regional health services. For the federal government,
efforts to facilitate a broader national perspective sensitive to rural
health must be made within pre-established jurisdictional boundaries.
CURRENT FEDERAL ATTENTION
TO RURAL HEALTH
Although calls for federal
attention to the health concerns of rural Canadians are not new, the late
1990s saw renewed commitment.(11) Federal
throne speeches, parliamentary reports and budgets indicated political
and financial commitment to the broad infrastructures needed to support
rural communities. In 1999, the Prime Minister created the Cabinet position
of Secretary of State for Rural Development. On rural health specifically,
Health Canada’s establishment of the Office of Rural Health in 1998
provided an institutional mechanism for applying the rural perspective
to departmental and national health efforts. The following sections explore
some of the recent federal departmental and parliamentary actions in the
area of rural health.
A. Key Federal
Departments Organizing for Rural Health
At the departmental level,
Health Canada currently takes a national leadership role in efforts to
maintain and enhance the health of all Canadians, including those living
in rural areas. It is expected to work in partnership with other federal
departments and agencies as well as with provincial and territorial governments.
This ability to work in a coordinated horizontal fashion to ensure an
integrated approach was a key theme of the 1999 federal framework for
rural action. Several of the 11 governmental priorities in the framework
have relevance to rural health; in addition to access to health care,
these include access to financial resources, human resource leadership
development, rural telecommunications and partnerships for community development.(12)
Health Canada supports rural
health initiatives through multiple efforts:(13)
-
rural
health needs (for example,
the Innovations in Rural and Community Health Initiative, and the
Canada Health Infostructure Partnerships Program);
-
affected
groups (for example, the First
Nations and Inuit Home and Community Care Program, and the National
First Nations Telehealth Project); and
-
rural
health concerns (for example,
the Health Transition Fund, Centres of Excellence for Women’s
Health, and the Canada Prenatal Nutrition Program).
In addition to Health Canada’s
direct role, the first annual report on federal departments’ and
agencies’ actions to meet the federal commitment to rural Canadians
cited multiple examples of initiatives by other departments either alone
or in partnership.(14) These included:
-
Environment
Canada with Health Canada helping rural communities make informed
decisions through the Community Animation Program on Health and Environment;
-
Public Works
and Government Services Canada working with Environment Canada to
clean up contaminated sites in remote areas and working with Indian
and Northern Affairs Canada to improve water and sewage facilities
on reserves;
-
Industry
Canada funding projects to improve the access of rural communities
to telehealth services;
-
Human Resources
Development Canada helping rural communities to increase their knowledge
of rural child development and care through Child Care Visions and
assisting eligible rural students to pursue post-secondary education
through the Canada Student Loans Program;
-
Agriculture
and Agri-Food Canada supporting food safety and quality through its
Canadian Adaptation and Rural Development Fund;
-
Veterans
Affairs Canada partnering with provincial departments and veterans
organizations to enhance access to health information and health technology;
-
Royal Canadian
Mounted Police addressing rural crime, suicide and family violence
through community participation.
As the preceding selective
list suggests, rural health is currently seen as a horizontal issue cutting
across multiple federal institutions. These federal bodies, in turn, interact
with provincial and territorial governments as well as a plethora of non-governmental
organizations that represent rural Canadians and rural communities or
groups that share an interest in some aspect of rural health. These non-governmental
organizations or groups, often called stakeholders or partners, are quite
varied in composition and mission. The multiple partners that influence
federal rural initiatives include:
-
aboriginal
entrepreneurs such as Peace Hills Trust and the National Aboriginal
Capital Corporation Association;
-
youth-oriented
bodies such as the YMCA and school associations;
-
academic-focused
associations for universities and colleges; and
-
health professional
bodies such as the Aboriginal Nurses Association and the Society of
Rural Physicians of Canada.(15)
Different federal ministers
with initiatives in the rural health area respond to this diversity in
their public interactions with the groups. Although Health Canada interacts
with the multiple non-governmental organizations that have a stake in
specific traditional and other broader health concerns, it also works
with diverse groups on broader health determinants affecting particular
populations. For example, during an address to the Canadian Federation
of Agriculture (a group representing farmers), the Minister of Health
announced plans to create a position of Executive Director of Rural Health.(16) From another departmental perspective, the Minister
of Industry spoke with the Empire Club and the Prince George Chamber of
Commerce about health technology and particularly information technology
for rural and remote areas.(17)
B. Parliamentary Initiatives
on Rural Health
Direct parliamentary activities
related to rural health were not prominent in the late 1990s. For example,
unlike the two earlier Parliaments, no House of Commons or Senate Committee
undertook a study specifically focused on the health of rural or remote
Canadians during the 36th Parliament (1997-2000).(18)
Parliamentarians of both
houses, however, raised the issue through direct questions during debate
or in committees studying broader health-related issues. For example,
during debate, parliamentarians referred to initiatives by federal departments
such as Health Canada or by non-governmental organizations such as the
Canadian Medical Association. In committees, the House of Commons Finance
Committee in its fall 1999 pre-budget consultations heard from the Society
of Rural Physicians of Canada about the need for a national rural health
strategy that would provide $150 million a year to fund programs
to train, recruit and retain health care providers in rural Canada.(19)
The 1999 federal budget,
presented to and approved by Parliamentarians, included $50 million over
three fiscal years (1999-2000 to 2001-2002) to support the Innovations
in Rural and Community Health Initiative. Of this total amount, $18 million
has been set aside specifically for rural initiatives: $11 million for
grants and contributions, $2 million for national policy projects, and
$5 million to support the Office of Rural Health.(20)
By June 1999, the National Liberal Rural Caucus had issued a report to
the Minister of Health calling for the development of a national rural
health strategy.(21) Several recommendations related to the need for Members
of Parliament to have effective tools for gathering information from rural
constituents about possible components of such a strategy.
Parliamentarians have primarily
been concerned with questions of what the federal government might do
in the area of rural health. Although sensitive to the fact that most
health care services were a provincial responsibility, they noted that
many innovations could be and have been facilitated by federal and provincial
collaboration. They sought greater understanding of how federal action
could be initiated and supported in areas of service and program funding,
training of health providers, and research.
DOMINANT
IDEAS INFLUENCING FEDERAL ACTION
IN RURAL HEALTH
Broadly speaking, the federal
government can, and does, work to protect rural health, promote rural
health, and support the rural health system. However, in the area of rural
health as in others, all its actions now and in the future are influenced
by certain interconnected factors characteristic of broader health debate;
these include constitutional authority, health strategies, funding mechanisms,
access to services, and availability of research evidence.
A.
Constitutional Authority
With respect to rural health
generally, the federal government’s constitutional role is not absolutely
clear. It could be argued that, constitutionally, the precise division
of power on health as distinct from health care is not defined. In 1982,
the Supreme Court of Canada stated:
…
‘health’ is not a matter which is subject to specific constitutional
assignment but instead is an amorphous topic which can be addressed
by valid federal or provincial legislation, depending on the circumstances
of each case on the nature or scope of the health problem in question.(22)
Generally, the provincial
governments have powers to regulate local health matters, particularly
the delivery of health care services, while the federal government relies
primarily on constitutional powers, such as those pertaining to criminal
law, spending, and peace, order and good government (POGG).(23)
This criminal law power
has been used to authorize actions over conduct that is dangerous to health
and forms the base for the Food and Drugs Act covering the safety
of foods produced rurally as well as drugs used for animals and humans.
Other legislation based on the same power such as the Tobacco Act and
the Pest Products Control Act could be seen as having a double-edged
effect for rural people; while designed to protect their physical health,
the controls could produce detrimental effects on crop production, commodity
prices and the overall economic health of the rural community.
In relation to the federal
spending power, involvement in health care is pursued through the administration
of the Canada Health Act and the Canada Health and Social Transfer.
The Canada Health Act sets certain national standards, and the
CHST ensures certain financial contributions to support the health-care
system.
The federal POGG power may
be a supplementary or alternative avenue to provide for federal legislative
initiatives in areas of "national concern" including environmental
actions. Other areas that are considered to be extra-provincial in nature
and with relevance for rural areas could include the prevention of the
spread of disease and the facilitation of interprovincial movement of
health professionals. In addition, the federal government – through
specific authority for groups such as veterans and First Nations people
on reserves – provides direct delivery of some health services. The
Canada Labour Code can also address the occupational health and
safety of employees in federally regulated economic sectors. This allows
some oversight of rural occupational health in relevant industrial sectors
such as interprovincial transportation, uranium and certain other mines,
telecommunications and Crown corporations.
B. Health Approaches
The application of different
health strategies or approaches is of particular interest in discussions
of a federal role in rural health. Most governments, provincial as well
as federal, agree that "there is more to health than health care."(24)
Provincial health system reviews since the late 1980s have agreed that
the definition of health must be broadened and the emphasis shifted from
curing to promotion and prevention through community-based rather than
institution-based care.(25)
Approaches such as population
health and health promotion involve all Canadians and, accordingly, may
give the federal government some authority through its constitutional
powers. Thus, health approaches that focus on socio-economic determinants
may be viewed as appropriate for federal action in rural health when distinguished
from a traditional health care emphasis on particular diseases and availability
of provincial medical services. Furthermore, any health approach that
aims at the promotion and preservation of the health of the broad Canadian
population could be distinguished from traditional health care services
for sick individuals.
Proponents of the "health
is broader than health care" approach claim that overall good health
in rural areas is more often determined by policies affecting employment,
education, housing and the general economy than by access to health care
through physicians and hospitals. Critics, on the other hand, argue that
this conceptual approach diverts attention away from meaningful change
of existing health inequalities among the rural Canadian population and
can lead to major cutbacks in health care services without guarantees
that resources will be reallocated. All argue that the federal government
will have to commit money, time and political will if it is to effectively
develop and implement positive rural health outcomes.
C. Funding
Distribution
Money provides the solid
financial base for ensuring continuity and stability in initiatives relevant
to rural health and well-being. The federal spending power continues as
the central basis for health involvement, enabling both direct and indirect
participation in rural health as in other health areas.
The best-known federal funding
for health is the Canada Health and Social Transfer (CHST). This block
fund was intended to give the provinces greater ability to reform their
systems to meet particular regional needs, by ensuring that the specific
social and health concerns of particular municipalities – including
those in rural and remote areas – were reflected in each province’s
approach. This, in turn, was to give various community sectors –
including health, social and educational service organizations –
more opportunity to consolidate efforts and to establish joint consultative
mechanisms.(26)
Because all the discretion
in dividing funds among health care, social assistance and post-secondary
education rests with the provinces, it is unclear how much funding goes
beyond the health services sector. The same inability to track such CHST
funds seems to apply to the additional $21 billion over five years agreed
to on 11 September 2000 in the First Ministers’ Action Plan
for Health System Renewal.(27)
Other funding that could
be directed to the broad needs of rural health flow through programs such
as those for veterans’ and First Nations’ health as well as
others such as the Health Transition Fund and the Health Infostructure
Support Program. For example, Health Canada provides Non-Insured Health
Benefits including drugs, medical supplies and equipment, dental care,
vision care and medical insurance premiums directly to the Status Indian
and Inuit populations and to the Innu of Labrador when these supplies
and services are not provided by other provincial or territorial agencies
or third-party plans.(28) Of the Health
Transition Fund’s $150 million for 140 projects, $14 million
was earmarked for 27 projects with a rural and remote focus.(29)
Even when federal money goes to rural health, it is difficult to measure
the effect on rural health outcomes in the four priority areas: home care,
pharmacare, primary care reform, and integrated service delivery.
Less directly but very significantly
for rural health status, the federal government has had an important role
in the health of rural communities through economic means such as farm
assistance and insurance programs, supply marketing strategies, transportation
services, and infrastructure. As federal policy in these and other areas
changed (e.g., privatization of CNR and abandonment of rail lines, the
closure of rural post offices, changes to employment insurance), it directly
affected rural Canada.
D. Access to Professionals
and Facilities
The federal role in monitoring
and administering the Canada Health Act and its five principles
(accessibility, portability, comprehensiveness, public administration,
and universality) is important in relation to rural needs for hospital
and physician services.(30) Of all
the Canada Health Act principles, accessibility may be the most
significant for rural residents. The executive director of the federal
Office of Rural Health noted the rural access problem, stating: "If
there is two-tiered medicine in Canada, it’s not rich and poor, it’s
urban versus rural."(31) Rural residents are limited to a smaller range of medical
professionals when seeking care and may be less able to avoid (or report)
extra billing or user fees.(32) For
example, it is estimated that the 30% of Canadians living in rural areas
receive care from 15% of the country’s physicians.(33)
If the insured health services are not available locally, rural residents
may have to travel long distances and incur additional costs for transportation
and other needs such as hotels.
The question of medically
necessary services, currently limited to hospital and physician services
defined by provinces, can have implications for rural residents who want
early hospital discharges so they can be close to their families. Any
initiatives for home care, pharmacare and telehealth must also be assessed
in light of both the Canada Health Act and particular rural applications.
In relation to telehealth for remote communities, Industry Canada’s
Community Access Program (CAP) is currently working to connect rural and
remote communities to the Internet, a particular problem when basic physical
access to single phone lines is still a barrier for many rural households
and businesses.
Even with advanced telehealth
structures, the recruitment and retention of all health professionals
(including nurses, technicians, social workers, psychologists and nutritionists)
to remote and rural areas will continue to be an issue. The federal/provincial/
territorial ministers of health considered strategies for physician resource
management in the early 1990s and by the end of the decade were examining
options for all health human resource development.(34) For example, the goal of the October 2000 Nursing Strategy
for Canada is "to achieve and maintain an adequate supply of nursing
personnel who are appropriately educated, distributed and deployed…"(35)
Although this document emphasizes that "in keeping with the Agreement
on Internal Trade, nurses within Canada should not be restricted from
practice in any province/territory,"(36)
other analysts have called for attention to the role of federal immigration
policy in limiting foreign health professionals. Graduates of foreign
medical schools currently face multiple challenges from governments and
professional associations when they try to obtain a licence to practice.(37)
E. Research
Currently, there are increased
calls for "evidence-based decision-making," i.e., basing decisions
about health actions on reliable evidence that determines whether particular
current procedures, practices or programs are effective or efficient.
To gain a fuller understanding of this within the rural health context,
Health Canada provided $200,000 to the University of Northern British
Columbia to host an invitational Rural Health Research Summit in October
1999. The report from this initiative highlighted the "blueprint"
for a health research process inclusive of rural citizens and observed
that "Just as rural health issues can be unique, the research needs
and approaches required to study and understand rural health are equally
distinct." (38)
Access to good health data
could mean funding rurally-relevant research and evaluation initiatives
(within existing bodies such as the Canadian Institutes for Health Research
and the Social Sciences and Humanities Research Council) as well as consistent
data collection and analysis on rural populations (within departments
and agencies such as Statistics Canada and the Canadian Institute for
Health Information). In fact, the newly created Canadian Institutes for
Health Research indicated that rural issues cut across the work of several
of their individual institutes (aboriginal, health services, etc.) while
the Canadian Institute for Health Information is organizing billing data
– both nationally and by province – for surgical, obstetrical
and anaesthetic services provided in rural Canada. Other organizations,
such as the Federal / Provincial / Territorial Canadian
Co-ordinating Office for Health Technology Assessment, could provide informed
evaluations of rural medical practices and technologies in areas such
as telemedicine.
As the Rural Health Research
Summit report noted:
-
few of the
existing funding agencies and foundations have made rural research
a high priority;
-
the establishment
of a Rural Health Research Initiative, a Rural Health Research Secretariat
and a Rural Health Research Foundation would demonstrate commitment
and to provide continuity for research programs and information dissemination;(39)
and
-
its proposed
blueprint for rural health research was congruent with sentiments
expressed by the federal government in its declarations on collaborative
policy-relevant research and evidence-based decision-making.
In the same vein of collecting
comparable evidence for decisions, the September 2000 First Ministers’
Meeting adopted an Action Plan on Health that called for clear accountability
as well as other elements.(40) This included comprehensive and regular
public reporting to Canadians with appropriate independent third-party
verification and the requirement to measure, track and report on comparable
indicators such as health status, health outcomes and quality of services.
Accountability through any "report card" on health should contain
measures of outcomes that are relevant to rural populations and their
particular situations.
CONCLUDING OBSERVATIONS
-
A person’s
geographic location and associated factors such as social support
networks, employment and working conditions, and health services availability
influence health status. In Canada, where almost one-third of the
population lives in rural areas, more detailed analysis of the connections
between rural residency and health is essential.
-
Continuous
and coordinated horizontal efforts – both among federal departments
and among federal, provincial and territorial levels of government
– can reduce unnecessary duplication and encourage shared learning
about rural health. Any actions in this area – including the
ongoing negotiations among federal, provincial and territorial officials
as well as annual debates among ministers of health and first ministers
– need to be more transparent and accessible to affected rural
populations including aboriginal peoples, youth, seniors, farmers,
etc.
-
Given the
breadth and ambiguity of its constitutional powers, the federal government
can continue to interpret its powers broadly and carry out key rural
health-related activities in the area of health policy development,
health regulation enforcement, healthy living promotion, disease prevention,
and health service provision to particular populations.
-
The distribution
of health funding in ways that ensure equitable treatment of rural
health concerns is not an easy task. Collaborative methods for tagging
and tracking CHST transfers and other health-related funding, although
difficult to achieve, could produce greater equity and efficiency
for rural health.
-
From a federal
perspective, in addition to a leadership and coordination role, the
Canada Health Act and various policies related to everything from
electronic systems to immigration can affect access, not only to medical
care by physicians in hospitals, but also to other essential health
professionals in other settings.
-
Research
has already been directed toward rural health, and the results have
been used to guide further work. However, there is still a need to
assign a higher priority to research establishing baseline data on
rural health status, special needs groups, effectiveness of existing
services, differing health behaviours, and other issues.
-
Rural health
partnerships between rural communities and governments must be based
on long-term commitments with full recognition both of geographical
barriers that make frequent physical connections difficult and of
the time and resource constraints that limit participation by rural
Canadians. Partnerships must guard against government downloading
efforts and must reflect the diversity of rural communities where
populations vary by age, ethnicity, occupational and other factors
that determine different health needs.
(1) William Ramp, "Where do we go from
here," in William Ramp, Judith Kulig, Ivan Townshend, Virginia McGowan
(eds.), Health in Rural Settings: Contexts for Action, Lethbridge:
University of Lethbridge, 1999, p. 297.
(2) Ibid., p. 17.
(3) Canada, Canadian Rural Partnership, Questions for
Rural Canadians: Rural Dialogue Workbook, Ottawa, 1998. http://www.rural.gc.ca/overvi_e.htm
(4) Canada, Rural Secretariat, Working Together
in Rural Canada: Annual Report to Parliament, Agriculture and Agri-Food
Canada, May 2000, p. 18. www.rural.gc.ca
(5) Federal, Provincial and Territorial Advisory
Committee on Population Health, Strategies for Population Health: Investing
in the Health of Canadians, Health Canada, Ottawa, 1994.
(6) Health Canada, Population Health Approach website.
http://www.hc-sc.gc.ca/hppb/phdd/
(7) Canada, Canadian Rural Partnership, Questions
for Rural Canadians (1998).
(8) Health Canada, Rural Health, Ottawa, 2000. http://www.hc-sc.gc.ca/ruralhealth/
(9) Canada, Rural Secretariat, Working Together
in Rural Canada (2000), p. 19.
(10) M. Watanabe with A. Casebeer, Rural, Remote and
Northern Health Research: The Quest for Equitable Health Status for all
Canadians, Report of the Rural Health Research Summit, Prince George,
British Columbia, October 1999, p. 4. http://www.unbc.ca/ruralhealth/
(11) Canada, Rural Secretariat, Working
Together in Rural Canada (2000), pp. 9-15.
(12) Federal Framework for Action in Rural Canada. http://www.rural.gc.ca/framework_e.html
(13) Health Canada, Taking Action on Rural
Health, Ottawa: Public Works and Government Services Canada, 2000.
http://www.hc-sc.gc.ca/ruralhealth/TakingAction.pdf
(14) Canada, Rural Secretariat, Working
Together in Rural Canada (2000).
(15) Canada, Rural Secretariat, Working Together in
Rural Canada (2000).
(16) Speaking Notes for Allan Rock, Minister
of Health, The Canadian Federation of Agriculture Annual Meeting, Ottawa,
February 1998. http://www.hc-sc.gc.ca/english/archives/speeches/cfafin.htm
(17) http://www.ic.gc.ca/cmb/welcomeic.nsf/searchEnglish/$searchForm?SearchView&Seq=1
(18) In earlier parliaments, a 1993 Senate Agricultural
Committee report focused on farm stress as an occupational hazard and
a 1995 House of Commons report focused on mental health among Indian,
Inuit and Métis.
(19) House of Commons, Standing Committee on Finance,
testimony from the Society of Rural Physicians of Canada, 9 November 1999.
http://www.parl.gc.ca/InfoComDoc/36/2/FINA/Meetings/Minutes/finamn10%288928%29-e.htm
(20) Health Canada, News Release, "Minister of Health
announces initiatives to benefit rural Canadians," 12 June 2000.
http://www.hc-sc.gc.ca/english/archives/releases/2000/2000_61e.htm
(21) National Liberal Rural Caucus, Toward Development
of a National Rural Health Strategy, Phase I, Ottawa, June 1999.
(22)
Schneider v. The Queen [1982] 2 S.C.R. 112 at 142.
(23) Dale Gibson, "The Canada Health Act and the
Constitution," Health Law Journal 4, 1996, pp. 1-33;
Martha Jackman, "The Constitutional Basis for Federal Regulation
of Health," 5(3) Health Law Journal, 1996, pp. 3-10.
(24) Federal, Provincial and Territorial Advisory Committee
on Population Health, Strategies for Population Health: Investing
in the Health of Canadians, Ottawa, September 1994.
(25) Sharmila Mhatre and Raisa Deber, "From Equal
Access to Health Care to Equitable Access to Health: A Review of Canadian
Provincial Health Commissions and Reports," International Journal
of Health Services, 22(4), 1992, pp. 645-668.
(26) For a general overview of the Canada Health and Social
Transfer, see Odette Madore, The Canada Health and Social Transfer:
Operation and Possible Repercussions on the Health Care Sector, 95-2E,
Ottawa: Parliamentary Research Branch, February 2000.
(27) First Ministers’ Meeting, Communiqué on
Health, 11 September 2000.
http://www.scics.gc.ca/cinfo00/800038004_e.html
(28) Health Canada, Non-Insured Health Benefits. http://www.hc-sc.gc.ca/msb/nihb/index_e.htm
(29) Health Canada, Rural Health: Information
Backgrounder, June 2000.
http://www.hc-sc.gc.ca/english/archives/releases/2000/2000_61ebk2.htm
(30)
For general discussion of the Canada Health Act, see Odette Madore,
Canada Health Act: Overview and Options, PRB 94-4E, Ottawa: Parliamentary
Research Branch, January 2000.
(31) "New Office to Focus on Rural Health Issues,"
Farm Family Health, 7(1) Spring 1999.
http://www.hc-sc.gc.ca/hpb/lcdc/publicat/farmfam/vol7-1/index.html
(32)
Therese Jennissen, Health Issues in Rural Canada, BR-325E, Ottawa:
Parliamentary Research Branch, December 1992.
(33) "Strategic investment needed for rural health,"
CMA News, 10(1), 11 January 2000, p. 6.
(34) News Release, "F/P/T Health Ministers
take action on key health issues," 16 September 1999; with respect
to access, Ministers received two discussion papers addressing physician
services for rural communities. http://www.hc-sc.gc.ca/english/archives/releases/1999/99_pice.htm
(35) Federal, Provincial and Territorial Advisory Committee
on Health Human Resources, The Nursing Strategy for Canada, October
2000, p. 2. http://www.hc-sc.gc.ca/english/nursing/nursing.pdf
(36) Ibid., p. 4.
(37) Health Canada, Medical Licensure in Canada: Information
for Graduates of Foreign Medical Schools, Online Edition, 1997. www.hc-sc.gc.ca (Search for "medical
licensure"; it is the first document listed.)
(38) M. Watanabe with A. Casebeer, Rural, Remote and
Northern Health Research (1999), p. 23.
(39) Ibid., p. 9.
(40) First Ministers’ Meeting, Communiqué on Health,
Ottawa (2000).
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