Health at a Glance
Difficulty accessing health care services in Canada
by Janine Clarke
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- In 2013, the majority of Canadians who needed health care (aged 15 years and older) did not report any difficulty with access (71%).
- Of those who reported difficulties accessing services, "waiting too long for an appointment" and "difficulty getting an appointment" were the most common problems reported.
- Canadians who reported fair or poor perceived health had the highest odds of reporting difficulty accessing specialized services such as specialist care, non-emergency surgery and selected diagnostics tests.
- Those with higher levels of education (i.e., at least some post-secondary) had the highest odds of reporting difficulty accessing first-contact services (e.g., immediate care, routine care or health information).
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Easy and timely access to health care services is important for the health of Canadians. Difficulty accessing services could result in: delays seeking and obtaining treatment, underuse or a lack of awareness of preventive health care or services, increased risk of complications if a diagnosis is delayed, increased financial burden on the health care system (e.g., if patients arrive sicker and/or need to stay longer in hospital), and/or decreased compliance with treatment.Note 1,Note 2 As such, an important goal of Canada's national health insurance program is to ensure that all Canadians have access to medically necessary services free of cost.Note 3,Note 4 However there are other factors, such as wait times, that can affect access to health care services resulting in some Canadians experiencing difficulty getting the care that they need.Note 2,Note 5
This article explores Canadians' (age 15 and older) self-reported experiences regarding access to selected health care services, in the year prior to answering the survey. Data are from the "Access to health care services" module which was asked to respondents in the 10 provinces as part of the Canadian Community Health Survey every 2 years from 2003 to 2013. The module asks specifically about two groups of health care services: specialized services and first-contact services.Note 6,Note 7,Note 8 Specialized services include specialist care, non-emergency surgery and selected diagnostic tests. First-contact services include immediate care, routine care and health information. The results presented in this article are based on the population who required health care services in the twelve months prior to answering the survey. The percentage of Canadians who reported one or more perceived difficulties accessing each of these health care services, along with the most commonly reported reasons for their difficulty, will be presented. In addition, we assessed the sociodemographic (e.g., level of education, employment status) and health characteristics (e.g., perceived health) of those respondents who reported difficulty accessing health care services. The characteristics examined in this article were previously found to be associated with difficulty accessing immediate or routine care.Note 2
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Specialized services is the term that will be used throughout this article to collectively refer to the following 3 types of health care services:
- Specialist care is care from a medical specialist, such as a cardiologist, allergist, urologist/gynaecologist or psychiatrist, excluding an optometrist, for a diagnosis or consultation.
- Non-emergency surgery is any scheduled or planned non-emergency surgery, such as cardiac surgery, joint surgery (e.g., knee or hip), caesarean sections and cataract surgery, but excluding laser eye surgery.
- Selected diagnostic tests are tests that include magnetic resonance imaging (MRI) scans, computerized tomography scans (CT scans), and angiographies provided in non-emergency situations.
First-contact services is the term that will be used throughout this article to collectively refer to the following 3 types of health care services:
- Immediate care is immediate care for a minor health problem such as fever, headache, sprained ankle, vomiting, minor burns, cuts, skin irritation, unexplained rash or other health problems or injuries due to a minor accident.
- Routine care is routine or on-going care provided by a family doctor or general practitioner for the respondent or the respondent's family member living in the same dwelling. This includes an annual check-up, blood tests, or routine care for an on-going illness.
- Health information is information or advice regarding a new or existing health condition or disease. This could include information over the telephone or directly from a health care professional. Information may be about: treatment, care or who to contact for care (e.g., doctor, emergency room, hospital clinic).
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Most Canadians did not report difficulty accessing health care services
In 2013, about 80% of Canadians aged 15 and older accessed one or more specialized or first-contact health care service in the year prior to being surveyed. Of those, the majority (71%) did not report any difficulty accessing services.
The remainder of this article, however, will focus on the Canadians who reported difficulty getting the care they needed. The percent of Canadians that reported difficulty accessing various health care services varied depending on the health care service. For example, 16% reported difficulty accessing non-emergency surgery while 23% reported difficulty accessing immediate care (Charts 1 and 2). For most types of health care services, the percentage who reported difficulty accessing care has not changed significantly since 2003. However, in 2013 the percentage who reported difficulty accessing specialist care or selected diagnostic tests was significantly lower compared to 2003 (Chart 1).
Data table for Chart 1Chart 1 Note 1,Chart 1 Note 2
|Year||Specialist care||Non-emergency surgery||Selected diagnostic tests|
|2003Chart 1 Note †||24||19||25|
|2007||25||19||20Chart 1 Note *|
|2009||23||17||19Chart 1 Note *|
|2011||23||18||20Chart 1 Note *|
|2013||22Chart 1 Note *||16||19Chart 1 Note *|
Data table for Chart 2Chart 2 Note 1,Chart 2 Note 2
|Year||Health information or advice||Routine care||Immediate care|
|2003Chart 2 Note †||16||16||24|
|2005||15||15||21Chart 2 Note *|
|2009||16||17Chart 2 Note *||25|
|2011||16||17||22Chart 2 Note *|
"Waiting too long" was the most common reason why Canadians reported difficulty accessing health care services
People who reported difficulty accessing health care services were asked a follow-up question regarding the reason(s) for their difficulty.Note 9 Although many different types of difficulties were reported (e.g., language problems, cost, transportation problems) the top 3 difficulties for each health care service were included (Table 1). This was done in order to limit the focus to the most important reasons. Furthermore, some of the difficulties could not be presented due to a small sample size.
|Reasons for difficulty, by type of health care service||Percent (%)||95% confidence interval|
|Difficulty getting an appointment||43||(40 to 45)|
|Waited too long for an appointment||51||(49 to 53)|
|Waited too long to see a doctor (in-office waiting)||17||(15 to 19)|
|Difficulty getting an appointment with a surgeon||31||(27 to 36)|
|Waited too long for surgery||60||(55 to 65)|
|Still waiting for surgery||14||(11 to 18)|
|Selected diagnostic tests|
|Difficulty getting an appointment||26||(22 to 30)|
|Waited too long for an appointment||53||(49 to 57)|
|Waited too long to see a doctor (in-office waiting)||22||(19 to 25)|
|Health information or advice|
|Difficulty contacting a nurse or physician||40||(38 to 43)|
|Waited too long to speak to someone||36||(34 to 39)|
|Did not get adequate information or advice||29||(27 to 31)|
|Routine or on-going care|
|Difficulty contacting a physician||23||(21 to 25)|
|Difficulty getting an appointment||48||(46 to 50)|
|Waited too long to get an appointment||38||(36 to 40)|
|Immediate care (minor health problem)|
|Difficulty getting an appointment||31||(29 to 34)|
|Waited too long to get an appointment||26||(24 to 29)|
|Waited too long to see a doctor (in-office waiting)||49||(46 to 52)|
Source: Statistics Canada, 2009, 2011 and 2013 Canadian Community Health Survey.
Reasons related to "waiting too long" were among the top three reasons for difficulties with accessing each type of health care service (Table 1). More than 50% of those who reported difficulty accessing any specialized services indicated that the problem was with wait times for an appointment. Wait times were also the main difficulty with access to non-emergency surgery, where 60% reported that they waited too long for surgery. The percentage of Canadians who reported waiting too long for non-emergency surgery has remained unchanged over time (data not shown).
Wait times for health care services is an important issue in Canada – in 2004, the First Ministers committed to a 10-year plan to reduce wait times in Canada for a number of services/procedures.Note 4 Although the current analysis indicates that a significant percentage of Canadians reported "waiting too long" as a barrier to accessing health care services, other recent reports suggest that wait times for certain procedures have improved in Canada since 2004.Note 10 In fact, the majority of Canadians are receiving procedures, such as hip or knee replacement, hip fracture repair, cataract surgery, or radiation therapy, in a "medically acceptable timeframe", which is defined as the amount of time that is appropriate to wait for a procedure based on clinical evidence.Note 11 However, what is considered a "medically acceptable timeframe" may not be considered an acceptable wait time from the perspective of the patient. Since the questionnaire did not specifically ask how long respondents had waited, it is not possible to determine if the wait time was outside the medically acceptable timeframe.
"Difficulty getting an appointment" was another reason why many Canadians experienced difficulty accessing both specialized and first-contact health care services (Table 1). This reason was given most frequently (48%) by people who had difficulty accessing routine care from a family doctor or general practitioner. Having difficulty getting an appointment could be related to physician availability in Canada. The number of physicians in Canada is continually increasing and in 2014 the physician-to-population ratio reached its highest ever (224 physicians per 100,000 people).Note 12 However, in that same year, about 15% of Canadians reported that they did not have a regular medical doctor.Note 13 This discrepancy may be due to the fact that of those 224 physicians per 100,000 people, only 51% are family doctors.Note 12
For those who have a family doctor, difficulty getting appointments could be related to how services are organized or delivered by their healthcare provider. The amount of time a physician spends on direct patient care in an average week has decreased since the late 1990's.Note 14 However, in the last decade, efforts have been made to improve access to health care through the availability of group practices and primary health care networks.Note 15,Note 16 Although, this model of health care delivery is not yet fully implemented in all provinces.Note 15,Note 16
Several factors are related to difficulty accessing health care services
Multiple logistic regression analysis was used to identify which of selected sociodemographic and health characteristics were associated with difficulty accessing specialized or first-contact health care services. The adjusted odds ratio for each characteristic found to be significantly associated with difficulty accessing health care services is presented in Table 2. It represents the odds of experiencing difficulty accessing health care services by a given characteristic (e.g., female) compared to a reference group (e.g., male), when the other characteristics were considered.
|Characteristics||Specialized services||First-contact services|
|Adjusted odds ratio||95% confidence interval||Adjusted odds ratio||95% confidence interval|
|15 to 64||1.51Table 2 Note *||(1.33 to 1.71)||1.67Table 2 Note *||(1.50 to 1.85)|
|65 or olderTable 2 Note †||1.00||Note ...: not applicable||1.00||Note ...: not applicable|
|MaleTable 2 Note †||1.00||Note ...: not applicable||1.00||Note ...: not applicable|
|Female||1.12Table 2 Note *||(1.01 to 1.23)||1.36Table 2 Note *||(1.27 to 1.45)|
|Level of education|
|Less than high schoolTable 2 Note †||1.00||Note ...: not applicable||1.00||Note ...: not applicable|
|High school||1.13||(0.91 to 1.41)||1.18||(1.00 to 1.39)|
|Some post-secondary or higher||1.40Table 2 Note *||(1.16 to 1.68)||1.75Table 2 Note *||(1.51 to 2.02)|
|Currently working - full timeTable 2 Note †||1.00||Note ...: not applicable||1.00||Note ...: not applicable|
|Currently working - part time||0.85||(0.72 to 1.01)||0.82Table 2 Note *||(0.73 to 0.91)|
|Not workingTable 2 Note 4||0.90||(0.80 to 1.01)||0.84Table 2 Note *||(0.77 to 0.91)|
|Immigrant||1.15Table 2 Note *||(1.01 to 1.3)||1.08||(0.98 to 1.20)|
|Canadian-bornTable 2 Note †||1.00||Note ...: not applicable||1.00||Note ...: not applicable|
|Yes||0.88||(0.70 to 1.1)||1.26Table 2 Note *||(1.07 to 1.47)|
|NoTable 2 Note †||1.00||Note ...: not applicable||1.00||Note ...: not applicable|
|Atlantic||1.06||(0.93 to 1.21)||0.98||(0.89 to 1.08)|
|Quebec||1.36Table 2 Note *||(1.18 to 1.56)||1.53Table 2 Note *||(1.39 to 1.69)|
|OntarioTable 2 Note †||1.00||Note ...: not applicable||1.00||Note ...: not applicable|
|Prairies||1.17Table 2 Note *||(1.03 to 1.34)||1.18Table 2 Note *||(1.07 to 1.31)|
|British Columbia||1.36Table 2 Note *||(1.17 to 1.57)||0.87Table 2 Note *||(0.76 to 0.99)|
|Poor or fair||1.83Table 2 Note *||(1.62 to 2.05)||1.64Table 2 Note *||(1.49 to 1.80)|
|Good, very good or excellentTable 2 Note †||1.00||Note ...: not applicable||1.00||Note ...: not applicable|
|Has a regular medical doctor|
|YesTable 2 Note †||1.00||Note ...: not applicable||1.00||Note ...: not applicable|
|No||1.14||(0.97 to 1.34)||1.43Table 2 Note *||(1.28 to 1.59)|
... not applicable
Source: Statistics Canada, combined 2009, 2011 and 2013 Canadian Community Health Survey.
Age, sex, level of education, immigration status, region of residence and perceived health were significantly associated with difficulty accessing specialized services (Table 2). The odds of reporting difficulty were significantly higher compared with the reference group among: those under the age of 65, females, immigrants, those with at least some post-secondary education and those who reported poor or fair perceived health. The odds of reporting difficulty accessing specialized services were also significantly higher for people living in Quebec or the western provinces (the Prairies and British Columbia) compared with Ontario.
The results for first-contact services were similar to those for specialized services, such that age, sex, level of education, region of residence and perceived health were significantly associated with difficulty accessing services (Table 2). However, people without a regular medical doctor and those who identified as Aboriginal (living off-reserve) also had significantly higher odds of reporting difficulty accessing first-contact services. By contrast, those living in British Columbia (as compared with Ontario) and those with either part-time or no employment (as compared with full-time employment) had a significantly lower odds of difficulty accessing first-contact services. These results are consistent with previous research in Canada, however the strength of the association is generally lower (i.e., all odds ratios are less than 2) in the present analysis which suggests that there may have been some improvement over time.Note 2,Note 17
There are many inter-related factors that may affect one's ability to access health care services, including personal factors (e.g., work schedule, family responsibilities) and system factors (e.g., availability of services). Together these have a complex effect on an individual's opinion about their access to health care which is important to consider when interpreting the results of this study. For many of the characteristics examined in this article, the higher odds of difficulty accessing health care may be related to a greater need for health care services. That is, there may be greater opportunity to experience difficulty because of more frequent use of health care services. For example, previous research in Canada and the United States has shown that women access health care services more than men.Note 17,Note 18,Note 19 In the present study, women had a higher odds of reporting difficulties accessing care than men. However, we could not assess whether difficulty accessing care was related to the number of times a person accessed services due to limitations of the questionnaire.
By contrast, some of the groups that had higher odds of difficulty accessing care (e.g., those with higher education) were less likely to have reported accessing health care in the year prior to the survey (data not shown). One possible explanation for this could be related to different expectations among different groups. For example, it has been suggested that those who are younger and those who are more educated may have higher expectations or be more critical of their experience.Note 20,Note 21,Note 22 As such, younger or more educated individuals may report more difficulty than their older or less educated counterparts.
Factors related to a person's availability is another possible explanation for experiencing difficulty accessing care. For example, those who work part-time or who do not work may experience less difficulty getting appointments because of a more flexible schedule compared with those who work full-time.Note 23
Income was also included in the analysis although the results are not presented in Table 2 because the association with difficulty accessing health care services was not significant. This is consistent with previous research showing that Canada's universal health care coverage does help to reduce income-based inequalities often associated with difficulty accessing health care services.Note 2,Note 18,Note 24
The results of this study show that on average about 29% of Canadians who required health care reported difficulty accessing these services. Wait times and difficulty getting appointments were the most commonly reported reasons for experiencing difficulty.
The results also showed that certain groups had higher odds of reporting difficulty accessing health care services. These included Canadians under the age of 65, females, those with higher levels of education, full-time workers, immigrants and those with poor or fair perceived health. Further research to understand why these groups are having difficulties is warranted.
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The Canadian Community Health Survey (CCHS) is a cross-sectional survey that includes self-reported responses related to health status, health care utilization and health determinants. The CCHS includes Canadians aged 12 years and over who live in the ten provinces and three territories. Persons living on reserves and other Aboriginal settlements in the provinces; full-time members of the Canadian Forces; the institutionalized population and persons living in the Quebec health regions of Région du Nunavik and Région des Terres-Cries-de-la-Baie-James were not included in the survey. Altogether, these exclusions represent less than 3% of the target population.
The Health Services Access module was asked to a subsample of respondents from the CCHS every two years (2003, 2005, 2007, 2009, 2011 and 2013) to gather additional information on health services and access to health care. The questions were asked to Canadians 15 years and older who lived in the ten provinces.
Weighted frequencies and cross-tabulations were used to estimate the percentage of people reporting difficulty when accessing health care services.
Weighted frequencies and cross-tabulations were also used to estimate the top three reasons for experiencing difficulty accessing health care services. For this analysis, three years of data (2009, 2011 and 2013) were combined in order to increase the sample size for the analysis. An increased sample size can help to reduce the random variation that can occur with small numbers.
Multiple logistic regression analysis was used to evaluate the association between the outcome variables (no difficulty versus difficulty accessing either specialized or first-contact health care services) and various sociodemographic and health characteristics, simultaneously. The sociodemographic characteristics that were examined were: age, sex, education, working status (not working, employed part-time or employed full-time), income, region of residence (Atlantic, Quebec, Ontario, Prairies or British Columbia), type of area of residence (population centre or rural area), immigrant status, Aboriginal identity (living off-reserve only). The health characteristic examined was perceived health (fair/poor versus good/very good/excellent). Whether or not the respondent had a regular medical doctor was also explored. All of these characteristics were included in the analysis at the same time. This allowed for the examination of one characteristic at a time by removing (i.e., holding constant or adjusting for) the effects of the other characteristics.
The results of the logistic regression are presented as adjusted odds ratios (Table 2). The value of an odds ratio can range from zero to infinity. It is interpreted as a measure of the size of the association between a given characteristic and the outcome (i.e., reporting difficulty accessing health care). The characteristics examined in this article are all categorical, and so the odds ratios are interpreted in comparison with a reference group within a given characteristic. For example, if the characteristic of interest is sex and the reference group is "males", then an odds ratio less than 1 means that the odds of the outcome occurring are lower for females compared with males. An odds ratio greater than 1 means that the odds of the outcome occurring are higher for females compared with males. An odds ratio equal to 1 means that the non-reference group is not different from the reference group (e.g. no difference between females and males reporting difficulty accessing care).
Three years of data (2009, 2011 and 2013) were combined for the regression analysis to increase the sample size. For all analyses, bootstrap weights were used to take into account the complex design of the survey.
Aboriginal refers to those who self-identified as First Nations, Métis or Inuk (Inuit) living off-reserve. Persons living on reserves and other Aboriginal settlements are excluded from the survey's coverage.
Immigrants are those who reported that they were not a Canadian citizen by birth, regardless of the length of time since they first immigrated to Canada.
Perceived health is derived from the answer to the question ‘In general, would you say your health is: excellent, very good, good, fair or poor?' For the purpose of the analysis, those who reported their health as "poor" or "fair" were grouped together while those who reported their health as "good", "very good" or "excellent" were grouped together. Perceived health is used as an indicator of overall health status.Note 7
Population centre refers to an area with a minimum of 1,000 persons and a density of at least 400 persons per square kilometre, based on the current census population count.Note 25
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Janine Clarke is an analyst with the Health Statistics Division at Statistics Canada.End of text box 4
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For more statistics and analysis on the health of Canadians and the health care system, visit the Health in Canada module. This module is accessible from the Statistics Canada website, under Features.
CANSIM Table 105-3069 Difficulties accessing immediate care for a minor health problem, among those who required care at any time of day, household population aged 15 and over, Canada, provinces and territories
How to cite this article
Clarke, J. 2016. "Difficulty accessing health care services in Canada." Health at a Glance. Statistics Canada Catalogue no. 82-624-X.
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