Global Dialysis Perspective: Canada
Peter G. Blake
Abstract
Canada is a federation of ten provinces and three territories, and health care is primarily a provincial responsibility. The provinces, therefore, have substantial autonomy in health care delivery but are required to follow the basic tenets of the 1967 Canada Health Act as a condition for receiving essential health care transfer payments from the federal government. These conditions include the key requirement that all essential medical services have a single public payer, and therefore, no private insurance systems are allowed to fund such services. Therefore, neither dialysis providers nor physicians can directly charge patients for dialysis care, and conversely, patients cannot pay extra to see a particular nephrologist or attend a particular dialysis unit. This is uniquely restrictive compared with other countries (1). Health care funds come from provincial tax revenues and from federal transfer payments. Exclusively public funding does not exclude private provision of health care, and indeed, most Canadian physicians are self-employed and reimbursed “fee for service” by provincial governments. Hospital care is delivered by “not for profit” hospitals that are nominally independent, but they are funded by the provincial ministries of health (1). The delivery of maintenance dialysis services described here will be primarily on the basis of the model used in Ontario, the most populous province with 40% of the entire population. Key points of difference from other provinces will be noted however. Maintenance dialysis is almost entirely provided by Renal Programs based in “not for profit” government-funded hospitals. These range from large academic centers associated with medical schools to modest-sized community hospitals. These Renal Programs typically provide in-center hemodialysis (HD), home peritoneal dialysis (PD), and often, home hemodialysis (HHD) as well as outpatient and inpatient nephrology. Most academic Renal Programs have an associated kidney transplant unit. Many of the Renal Programs operate in …