The State of Rural and Remote Health Care in Canada

By Sipan Haikazian

Section 3 of the Canada Health Act of 1984 states as its primary objective: “to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers”.1 Despite the talks about long emergency room (ER) wait times, waitlists for certain physician consultations, and COVID-19-related setbacks, downtown Toronto and other large urban centers have a plethora of hospitals and health-related services available for its citizens to access. Most of us would not compare the health care we observe to that of a third-world or underdeveloped country. After all, we have some of the best health care in the world.

For citizens of the two Wapekeka First Nation Reserves (pronounced Wap-ehkey-ka) located in Northern Ontario, a very different health care system is in place. The estimated 350+ residents across the reserves have access to rudimentary health services, with the only permanent health staff being a few registered nurses. X-rays and other health imaging equipment are not present.2 A family physician visits the reserve for only a week out of the entire month. For more severe conditions, residents must board a plane and fly 450 km to Sioux Lookout, the “Hub of the North.” The Sioux Lookout Meno-Ya-Win Health Centre provides care for citizens of Sioux Lookout and the numerous other northern remote communities, whose citizens must also travel great distances to access the coveted health care services.2

Wapekeka and the other communities in Northern Ontario are classified as some of the most remote communities in Canada and together, their area makes up the size of France.2 What determines whether a community is remote or not is done using the remoteness index presented by Statistics Canada.3 Using population size, proximity to other populations and services, and travel cost, this index measures how disconnected some populations are from the rest of Canada. A critical study, published in 2019 by Statistics Canada, found that mortality rates, both preventable and treatable, are higher in remote areas.4 Combined with previous knowledge about higher avoidable mortality in many Indigenous groups, these studies demonstrate that access to healthcare and treatment is not equal for all Canadians.4

So, why might this be?

Rural communities receive less funding for health care than urban areas due to the segregated nature of the communities and the smaller number of people who reside there. In addition, health care worker shortages exist in these communities. In 2020, the Canadian Institute for Health Information (CIHI), a corporation that provides data on Canada’s health systems and population-wide data, reported that just 7.6% of physicians in Canada practice in rural areas.5 In Nunavut, a territory where all practicing physicians are said to be practicing in rural areas, the ratio of physicians per 100,000 patients numbered

63. In contrast, Ontario’s ratio was 229, nearly a four-fold difference.5 In addition, just 4.4% of Ontario’s 33,830 physicians practice in rural areas.5

In many rural and remote communities in Canada, the family physician acts as a general practitioner while taking on more specialized responsibilities typically fulfilled by anesthesiologists, pediatricians, and mental health specialists.6 Looking at data from the physician residency match of 2022, 99 positions for family medicine remained unfilled even after two rounds of matching, up from 89 in 2021. With 1,399 positions available, 7% of spots are not being filled up, with many communities not having access to enough family physicians.6 No other medical speciality comes close to the number of unfilled positions. It should go without saying that specialist care in Canada also suffers: a recent study looking at patients living in a community in Northwestern Ontario found that living in a rural area is associated with a decreased likelihood of receiving a specialist oncology consultation.7

But what about nurses, essential healthcare workers in both urban and rural health networks? According to data from 2010, the number of registered nurses working in rural areas per 100,000 is half that of urban areas.8

Why do so many healthcare workers not choose to work in these communities?

Why do so many healthcare workers not choose to work in these communities?

For many, it’s a lack of appeal. These communities are separated from urban centers and sometimes even other communities. Healthcare workers are hundreds of kilometres away from their family and friends. Workers may be dissuaded from starting families in these communities due to a perceived lack of funding and attention to services like education. Not to mention the lesser healthcare resources and funding these communities receive, which adds to workers’ hesitation.

In response to the stresses placed on rural health and well-being, the Rural Roadmap for Action (RRM) was developed by a task force created by the College of Family Physicians and the Society of Rural Physicians of Canada.9 It lists 20 recommendations for planning and executing rural healthcare services and aims at interventions in universities, policymakers, health professionals, and the communities that will be served.9 Thus far, they have implemented strategies to improve patient transport from urban to rural areas, integrate input from Indigenous health leaders, and advocate for the CIHR to increase funding in rural health research.9

Some provinces have already begun implementing their own programs to improve access to healthcare. The government of British Columbia has responded by increasing the number of doctors and paramedics in professional schools, training nurses to work in rural and remote communities, and scaling up virtual care.10 Other proposed strategies to help chip away at the problem include providing incentives to healthcare workers to work in these communities, increasing resources for workout fatigue, and helping patients access clinical trials for novel interventions for complicated diseases.

With the help of policies, interventions, and increasing attention to the problem, the fight to get equal access to healthcare for all Canadians is ongoing. It is up to the stakeholders in Canadian health care, including future physicians and researchers studying with IMS, to help solve the problem.

References

1. Canada Health Act 1984 (Can) c. 6, s. 3.

2. CBC News: The National. Canada’s struggle to provide health care to northern communities [video on the Internet]. 2018 March 5. Available from: https://youtu.be/0stGbq22cL0

3. Alasia A, Bédard F, Bélanger J, Guimond E, Penney C. Measuring remoteness and accessibility – A set of indices for Canadian communities. Statistics Canada. 2019 May 9.

4. Subedi R, Greenberg TL, Roshanafshar S. Does geography matter in mortality? An analysis of potentially avoidable mortality by remoteness index in Canada. Health Rep. 2019 May 15;30(5):3–15.

5. Canadian institute for Health Information. Supply, distribution and migration of physicians in Canada 2015 – data tables [Internet]. Canadian institute for Health Information, 2016 [cited 2022 Oct 18]. Available from: https://secure.cihi.ca/estore/productSeries. htm?pc=PCC34

6. Canadian Resident Matching Service. 2022 R-1 match data snapshot [Internet]. Canadian Resident Matching Service. 2022 May 12 [cited 2022 Oct 18]. Available from: https://www.carms.ca/pdfs/2022-R-1data-snapshot.pdf

7. Febbraro M, Conlon M, Caswell J, Laferriere N. Access to Cancer Care in Northwestern Ontario—A Population-Based Study Using Administrative Data. Current Oncology. 2020 Jun 1;27(3):271–5.

8. MacLeod MLP, Stewart NJ, Kulig JC, Anguish P, Andrews ME, Banner D, et al. Nurses who work in rural and remote communities in Canada: a national survey. Hum Resour Health. 2017 Dec 23;15(1):34.

9. Wilson CR, Rourke J, Oandasan IF, Bosco C. Progress made on access to rural health care in Canada. Can Fam Physician. 2020 Jan;66(1):31-36.

10. British Columbia Ministry of Health. New health workforce strategy improves access to health care, puts people first [Internet]. Vancouver: British Columbia Government; 2022 Sep 29 [cited 2022 Oct 18]. Available from: https://news.gov.bc.ca/27538