Systems for the management of respiratory disease in primary care - an international series: Canada.

Canada has a universal health care system funded by the government. All people are supposed to have unrestricted access to all essential health care in a timely fashion. Canada has ten provinces and three territories. Health care is funded by each province/territory, with federal payments providing some of the funding. The bulk of the provision of respiratory care in Canada is provided by primary care practitioners. Across the country we have a family physician shortage; thus, in many areas of the country there is insufficient access since patients do not actually have a family physician. This has less effect on acute medical services, which can be available in ER or walk-in settings, but certainly does affect the provision of services for chronic illnesses. While thus far the health care system is 'free', there are some significant limitations; the commonest is waiting times for specialist care and investigations. Other significant deficiencies include the lack of coverage for medications for both acute and chronic conditions and of medical devices. Primary care reforms by local governments have attempted to fix these issues by changing care models. Fee-for-service medicine by physicians is slowly being changed in places to capitation models and other systems such as rewards for managing chronic conditions optimally. Ontario has instituted 'reward systems' for diabetes and smoking cessation. British Columbia has rewards for multiple chronic diseases. In many areas, care in the provinces is regionalised to allow local arrangements to help decide on where and how care is organised. Respiratory diseases (excluding lung cancer) rank fourth in Canada in the total proportion of direct health care costs (behind neuropsychiatric, injury and cardiovascular diseases). A number of studies have shown that respiratory conditions such as asthma and COPD are underdiagnosed and/or undermanaged. Other conditions need treatment by specialists or physicians with a special interest (TB, cystic fibrosis, lung cancer) and access to these physicians also is a barrier to health care provision. Health care systems are thus part, but not all, of the problem.