i OVERVIEW

Canada is a federated country comprising 10 provinces and three territories,2 populated by over 37 million people.3 Under a 'separation of powers' concept, Canada's Constitution allocates responsibility for various matters between the federal government of Canada on the one hand, and the provincial governments on the other. Thus, while the government of Canada is responsible for the delivery of healthcare to a subset of Canada's population,4 generally, the regulation and funding of healthcare is within the provincial jurisdiction.

Regulating the delivery of healthcare is a significant function of our provincial governments. This fact is not surprising, given that the delivery of healthcare is, year in and year out, among the issues of greatest import to Canada's populace, and given that it was the subject of between 35 (Quebec) and 41 (Ontario) per cent of the provincial governments' budgets in 2018.5 Provincial legislatures pass laws relating to, among others: healthcare delivery; health protection and promotion; the governance and operation of facilities in which healthcare is delivered; the regulation of healthcare professionals; healthcare privacy, procurement, accountability and transparency; and the means by which physicians may be compensated for the provision of their services.

ii THE HEALTHCARE ECONOMY

i General

The Canada Health Act, a federal statute, is the single most important statute in defining how healthcare is delivered in Canada – even though, as said above, under the Canadian Constitution, the federal government has no jurisdiction to regulate healthcare. How then did it acquire this influence? Through its purse. The Canada Health Act is a funding statute. In it, the federal government sets out a number of conditions that must be met annually for the provinces to be entitled to their full share of the Canada Health Transfer for that year. Aggregating billions of dollars,6 no province can afford not to be in compliance.

ii The role of health insurance

To meet the conditions of the Canada Health Act, each province must have a health insurance plan in effect that, among other things, is:

  1. publicly administered;
  2. comprehensive;
  3. universal;
  4. portable; and
  5. accessible.

To be accessible, provincial health insurance plans must prohibit extra billing and user charges for medically necessary healthcare services.

While a detailed description of each of these criteria is outside the bounds of this chapter, the result is that each province has its own government-operated health insurance plan that pays for insured health services, meaning medically necessary healthcare services rendered to insured persons. While the provincial plans vary in a number of ways and provide some limited exceptions, for the most part, Canadians receive all medically necessary healthcare through their provincial health insurance system. In fact, all persons other than the provincial health insurance plans – including hospitals and healthcare providers, for example – are prohibited by provincial law from charging Canadians for medically necessary healthcare. Canada is one of only two countries in the world that makes the purchase of supplemental or private healthcare for medically necessary healthcare services illegal.

Although the term 'medically necessary' is not necessarily used or defined in provincial health insurance statutes, it has come to mean any healthcare service a province has agreed to fund in the fee schedule to its health insurance plan statute. Similarly, although for ease we refer in this chapter to 'Canadians' as those who are entitled to the benefits contemplated by the Canada Health Act and the provincial health insurance statutes, technically those entitled to such benefits are 'insured persons'. An insured person is an 'eligible resident' of a province (generally, someone who lives in a province for a specified amount of time per year, whether or not the person is a Canadian citizen, and including landed immigrants).7

iii Funding and payment for specific services

Most provincial health insurance statutes prohibit private insurance companies from selling insurance for medically necessary healthcare services delivered to Canadians. Nonetheless, a limited private insurance market exists, including for example:

  1. dental services (as only dental services delivered in hospital, and dental services provided to certain age groups and those living below specified income levels, are covered by the provincial health insurance plans);
  2. prescription drugs (as, with limited exceptions, including in the case of drugs prescribed to seniors, to those under the age of 25 without private insurance in Ontario, those with specific conditions and to those living below specified income levels, only drugs administered in hospital are covered by most provincial health insurance plans); and
  3. non-medically necessary services (e.g., most physiotherapy, chiropractic services and home care).

iii PRIMARY / FAMILY MEDICINE, HOSPITALS AND SOCIAL CARE

i Access to and delivery of healthcare services

The desired entry point for healthcare in Canada is the general practitioner or family physician. Nearly all other practising physicians in Canada are specialists (e.g., surgeons, oncologists). Access to patient-facing specialists is generally obtained via referral from a family physician.

It is expected that most patients will have their primary healthcare needs met through their family physician in the family physician's office. However, because not all patients have family physicians, and because family physicians are not always accessible in a timely manner, a large number of Canadians continue to have their primary healthcare needs met through hospital emergency departments or after-hours clinics. Both modes are considered inefficient and expensive. A growing number of hospital-sponsored urgent care centres and telemedicine solutions are emerging to meet patient demands stemming from, among other things, the inaccessibility of their family physician.

Healthcare is delivered in a number of settings:

  1. private clinics: including the offices of physicians and other specialists;
  2. surgical centres, or in Ontario, independent health facilities: generally, for specialty day surgeries or diagnostic procedures;
  3. community health centres: clinics for marginalised or other specific populations;
  4. community centres: clinics for specialised procedures provided by allied health professionals, such as infusion clinics or for speech pathology or physiotherapy;
  5. hospices: for palliative or end-of-life care;
  6. private homes or seniors homes: where patients receive 'home care', including clinical and non-clinical care, and respite care for family caregivers;
  7. hospitals: of which there are many types – acute, chronic, tertiary, community, etc.; and
  8. long-term care (nursing) homes.

It should be noted that because not all healthcare services are medically necessary, and thus not insured services under provincial health insurance plans, services in a number of the above settings may be paid for privately, including by the individuals receiving such services and their private insurers.

In response to challenges facing healthcare delivery, notably exceedingly long waiting times for necessary care, duplication and lack of coordination among care providers, the pressures of an aging population and the prevalence of chronic diseases, provinces are replacing institution-centred approaches with patient-centred approaches. Ontario, for example, is transitioning towards a more coordinated model for delivery of healthcare, through which patients within a specified geography will receive integrated care, including, for example, primary care, hospital services, mental health and addiction services, long-term care and community care from healthcare providers forming part of the same 'Ontario Health Team'.

ii Electronic health record

For a number of years, Canada has been developing a national electronic health record (EHR) system, through a collaboration of the government of Canada, the federal agency Canada Health Infoway, provincial governments and other health sector organisations. EHRs are intended to ensure that patient records are readily accessible by healthcare providers across the country and to increase compatibility across different provincial or regional systems.

The national EHR initiative is supplemented by other provincial electronic health record initiatives. For example, provinces have provided support in respect of the conversion of paper-based systems to electronic systems at family physicians' offices and hospital systems, and have also independently developed systems that focus on particular aspects of the health sector, such as chronic disease management.

While the EHR system is developing at local, micro levels, secure connectivity between sites and large-scale application is still on the horizon.

iii Services to support seniors

As Canada's population continues to age, services and programmes to support the health needs and social well-being of seniors continue to be necessary components along the continuum of care. The majority of the provincial governments offer or provide services and programmes to benefit the health and social needs of seniors. For example, home care services and community support services are generally funded, at least in part, by the provinces and aim to keep seniors living within their residences for as long as possible, thereby reducing unnecessary hospital admissions and lengthy hospital stays. Many of the services offered by the provincial governments are provided for or coordinated in partnership with community agencies.

IV THE LICENSING OF HEALTHCARE PROVIDERS AND PROFESSIONALS

i Regulators

Healthcare professions are regulated by profession-specific 'colleges', each of which is a not-for-profit corporation established by profession-specific statutes. In Ontario, for example, there are currently 26 colleges, including the College of Physicians and Surgeons of Ontario, which governs the profession of medicine in the province.

Each college has a council that manages and administers the college's affairs and functions as the college's board of directors. Generally, colleges are funded by the healthcare professionals that comprise their membership, but some receive partial operating funding from the government.

The provincial legislation that is applicable to healthcare professions sets out to protect the public by, among other things, establishing the scope of the practice of the profession and restrictions on who can practise the profession. Colleges are required by this legislation to, among other things, ensure that the public has access to qualified, skilled and competent healthcare professionals. Colleges seek to uphold this obligation by, for example, developing, establishing and maintaining standards of practice, quality assurance programmes, and standards of professional ethics. The profession-specific legislation also generally provides colleges with authority to investigate complaints regarding their members' conduct and to impose disciplinary measures on their members in prescribed circumstances.

ii Institutional healthcare providers

Professionals within institutional healthcare providers

Employers in Canada have vicarious liability for certain of their employees. Thus, healthcare providers are diligent in ensuring that the healthcare professionals they employ are qualified and licensed to practise. Where healthcare providers deliver healthcare services in a hospital, long-term care home or other healthcare institution on a non-employed basis (e.g., physicians and dentists as independent contractors to hospitals), the institution applies the same rigour but to a higher scale, knowing that in most cases it is these non-employed professionals who will be overseeing and directing the care provided by other professionals.

Institutional healthcare providers themselves

With a limited number of exceptions, hospitals in Canada are charitable organisations that are not privately owned. They are not licensed per se, but are classified by the government as to type (e.g., acute, chronic, tertiary, community) and receive funding from their provincial government (or a government intermediary). The funding is based on a number of criteria, including population base, patient composition and fixed-service fees. In some provinces, hospitals are overseen by volunteer boards; in other provinces, they are overseen by a regional authority. Hospitals are not legally limited in the services that they offer, but given that nearly all their operating revenue comes from the provincial government (or a government intermediary), generally they cannot expand into new service offerings without government support.

Long-term care homes and independent health facilities (Ontario) (which provide insured services) are operated under licence. A large percentage of the long-term care homes and independent health facilities are privately owned, and a market exists for the purchase and sale of such licences. It is noted, however, that long-term care home licences and independent health facility licences cannot be transferred without the consents required by the applicable statute.

Subject to the comments above regarding long-term care homes and independent health facilities, generally, in most provinces, licences are not required to operate private clinics that are not engaged in surgical procedures. However, in several provinces, such as Alberta, British Columbia, Manitoba, Ontario, Quebec and Saskatchewan, private clinics providing surgical procedures are subject to accreditation or licensure by the college governing the medical profession.

iii Healthcare professionals

As noted above, the requirements for registration or licensure8 as a member of a healthcare profession are set out in the various provincial health profession statutes described in Section IV.i. In general terms, the registration requirements for healthcare professionals include: (1) having a degree in his or her area of practice from an accredited school, or a degree that is determined to be equivalent by the relevant college; (2) successfully completing certain postgraduate training or education; and (3) passing certain qualifying examinations or assessments. It is also a general registration requirement that an applicant's past and present conduct afford reasonable grounds for the belief that the applicant will practise the profession competently and with integrity.

Healthcare professionals are required to have professional liability insurance, generally as a requirement of registration with a college.

The health profession Acts also often provide a means by which healthcare professionals who are members of colleges in other provinces can have their extra-provincial credentials recognised without having to go through the entire registration process anew.

Some healthcare professions have different classes of registration or certification (e.g., student class, practitioner class), each of which attract distinct qualification requirements. Moreover, different classes of certification may have different terms, conditions and limitations imposed on the certificate of registration, which limit the healthcare professionals' scope of practice (e.g., limitations on ability to provide healthcare independently).

Where the registrar of a college has doubts as to whether an applicant fulfils the registration requirements, or is of the opinion that terms, conditions or limitations should be imposed on a certificate of registration, notice is normally provided to the applicant and the applicant is given an opportunity to make submissions in response to same.

The health profession Acts provide that a member's contravention of a term, condition or limitation imposed on his or her certificate of registration constitutes an act of professional misconduct.

Where a healthcare professional is found by the court to have contravened a health profession Act, he or she may be subject to sanctions established by the applicable health profession Act (e.g., suspension or revocation of the member's certificate of registration, a fine or imprisonment).9 Examples of actions that are likely to contravene health profession Acts include:

  1. Except in the case of certain limited exceptions, it is an offence to perform a controlled act (i.e., an activity that can cause harm if it is performed by an unqualified person) unless the controlled act is performed by a member authorised by a health profession Act to perform the controlled act, or the performance of the controlled act has been delegated by an authorised person to another person.
  2. It is also an offence for someone other than a healthcare professional acting within the scope of his or her practice to treat or advise a person where it is reasonably foreseeable that serious bodily harm may result from the treatment or advice.
  3. It is also an offence to commit an act of professional misconduct.

The health profession Acts also incorporate procedural fairness provisions that give members an opportunity to be heard and challenge decisions regarding their conduct, including through a court process.

V NEGLIGENCE LIABILITY

i Overview

Negligence claims are pursued through proceedings in court. To succeed in a claim for negligence, a plaintiff must establish that the defendant owed him or her a duty of care, the defendant breached that duty by falling below the standard of care, the plaintiff suffered damage, there is a causal connection between that damage and the negligence, and the damage was reasonably foreseeable.

It is legally established that healthcare providers owe a duty of care to their patients. The duties owed by healthcare professionals have broadened in scope over time to include, for example, the duty to obtain informed consent. Healthcare professionals are held to the standard of a normal and prudent professional of similar experience, expertise and standing. Damages for negligence may include general damages for pain and suffering, loss of income, expenses incurred as a result of the negligence, and the cost of future care. Close family members may also be entitled to damages for loss of care, guidance and companionship, as well as compensation for services they have provided to the plaintiff. Causation is proved by demonstrating that the injury would not have occurred 'but for' the defendant's negligence on a balance of probabilities.

Healthcare facilities, such as hospitals, can be held directly liable for negligent management or administration of the facility where the negligence causes or contributes to the damage to the plaintiff. For example, a healthcare facility may be found liable for failing to properly train or supervise employees, protect patient confidentiality, or hire competent staff. Healthcare facilities may also be held vicariously liable for the negligence of their employees (which would not normally include physicians, as physicians are typically not employees of the facility, other healthcare professionals, such as registered nurses).

ii Notable cases

R v. John Doe, 2016 FCA 191

Privacy class actions involving healthcare providers are an emerging area. A motions judge of the Federal Court certified a class proceeding against the Crown brought by two anonymous plaintiffs on behalf of participants in the Marijuana Medical Access Program. The plaintiffs allege that Health Canada sent them oversized envelopes addressed with their names and with a return address to the Program (thereby revealing the plaintiffs' association with the Program). The plaintiffs alleged a number of causes of action, including intrusion upon seclusion, and publicity given to private life. The class action followed a finding by the Office of the Privacy Commissioner that Health Canada had violated federal privacy laws.

The Federal Court of Appeal confirmed the certification order, but only with respect to the causes of action of negligence and breach of confidence. The Court overturned the certification order with respect to the claim for intrusion upon seclusion and publicity given to private life, because the plaintiffs had not pleaded the material facts in support of the necessary elements of those causes of action.

The Christian Medical and Dental Society of Canada et al v. College of Physicians and Surgeons of Ontario, 2019 ONCA 393

In 2019, the Ontario Court of Appeal (ONCA) upheld the Superior Court's decision that two policies of the College of Physicians and Surgeons of Ontario (CPSO) regarding Medical Aid in Dying (MAID) are constitutional. The crux of this challenge focused on the CPSO's MAID policy, requiring physicians who are unwilling to provide elements of care on moral or religious grounds to provide patients requesting that care with an effective referral to another healthcare provider. The CPSO argued that the policy was necessary to protect patients, while the plaintiff argued that the policy required healthcare practitioners to act in contravention of their sincerely held religious beliefs, breaching their right to freedom of religion. The policy was adopted by the CPSO after the Supreme Court of Canada struck down the legislation criminalising physician assisted suicide in 2015.

On appeal, the ONCA balanced the healthcare practitioners' rights to freedom of religion, set out in the Canadian Charter of Rights and Freedoms, with the patients' right to equal treatment without discrimination based on characteristics such as mental or physical disability. The Court concluded that although the policy does infringe on health practitioners' freedom of religion, that infringement is justified because of the paramount importance of ensuring equitable access to healthcare, and because the policy minimally impairs the religious freedom of the healthcare practitioners. Physicians have a duty not to abandon patients.

The courts showed some deference to the CPSO's policy judgement on how to balance physician interests and patient needs because as a self-governing professional body with institutional expertise, the CPSO is better suited to decide the policy in balancing these interests. The fact that other jurisdictions have established policies that the appellants regarded as less impairing was not persuasive to the ONCA, since a right is 'minimally impaired' so long as the policy in question is within a range of reasonable alternatives to achieve the underlying policy goal but respect individuals' rights.

DD v. Wong Estate, 2019 ABQB 171

In 2016, the Supreme Court of Canada clarified the law regarding causation in medical negligence cases. In its decision of Benhaim v. St-Germain, 2016 SCC 48 (CanLII), the Supreme Court stated that the approach to factual causation should be 'robust and pragmatic' and a trier of fact can draw inferences even without scientific expertise sufficient to arrive at a definitive conclusion. The Court of Queen's Bench of Alberta has recently applied that decision in a medical malpractice lawsuit against a gynaecologist and an obstetrician. After a trial, the judge found that the doctors failed to identify intrauterine growth restriction quickly enough, failed to tell the patient about the risks of her pregnancy, including the risks of growth restriction, and failed to recommend that labour be induced early.

The trial judge held that, to prove causation, the plaintiffs had the burden to prove that injuries would have been avoided with proper diagnosis and treatment. The trial judge accepted the plaintiff's evidence that she would have been induced if she had been provided with complete and timely information about her options. The trial judge also cited Benhaim for the proposition that where there is causal uncertainty created by the defendants' negligence, it can but does not necessarily mean that the burden of proof is shifted from the plaintiffs to prove causation or that an adverse inference should be drawn against the defendants. Here, the trial judge found no such adverse inference necessary and concluded that the evidence was sufficient to prove causation. The defendants were found liable for the plaintiffs' injuries.

VI OWNERSHIP OF HEALTHCARE BUSINESSES

While healthcare in Canada is generally paid for publicly, it is delivered in large part by those in private business, including physicians and operators of private clinics, long-term care homes, and, in Ontario, independent health facilities.

Although some physicians are hospital employees (e.g., radiologists, those working in labs and research areas, and a limited number of hospitalists), most physicians are self-employed or working in partnership with other physicians. Physicians may incorporate medical professional corporations to enter into leases and other non-clinical agreements. In most provinces, physicians must hold all the voting shares of medical professional corporations, but their spouses or family members, or in some provinces other persons, may own non-voting shares of such corporations (provided that the physicians themselves remain liable for the professional services they provide). The same is true for certain other healthcare providers. A market exists for the purchase and sale of all such corporations, subject to applicable provincial law and the policies of each regulatory college, but control of these professional corporations is limited to other healthcare professionals of the same designation.

Non-professionals may provide services to professional corporations and so may indirectly participate in the business arrangements of the professionals. Private corporations that provide space and other administrative services to healthcare professionals are common. Opportunities exist for purchase and investment in these service corporations. Notwithstanding their private nature, these corporations and the professionals practising within them are required to comply with the provincial laws prohibiting private payment for insured services. Private payment for insured services is at the centre of a high-profile case that originated in British Columbia, Cambie Surgeries Corp v. British Columbia (Attorney General).

Like other provinces, British Columbia prohibits the use of private insurance for insured services and does not allow services provided in private surgical clinics to be billed outside the public insurance plan. The constitutionality of these restrictions is being challenged at this time by Cambie Surgeries Corp, an owner and operator of two private healthcare facilities in British Columbia. Cambie alleges that prohibitions on extra billing and private insurance violate Canada's Charter of Rights and Freedoms by limiting timely access to medical services for residents. While British Columbia's public insurance legislation does not preclude private clinics or private billing, it prohibits a public–private model such as Cambie's, in which a private clinic engages in extra billing (billing a patient directly for an insured service) in addition to receiving funding for insured services. While the trial has faced numerous procedural delays since it started in 2016, as at June 2019, the trial had resumed, after a long adjournment and dozens of evidentiary hearings, and was ongoing. It is anticipated that the decision of the court will eventually be appealed to the Supreme Court of Canada, as it could have a significant impact on how healthcare services are delivered and funded in Canada.

VII COMMISSIONING AND PROCUREMENT

Some Canadian healthcare providers (e.g., hospitals and health authorities) are subject to public procurement rules. These rules arise out of international trade agreements; national and regional domestic trade agreements; provincial statutes and procurement directives; and the specific policies of each public sector purchaser. Procurement rules are intended to ensure fairness, transparency and accountability in decisions about the use of public funds. They apply to contracts for the purchase of goods or services that meet or exceed certain value thresholds. Generally, these rules require those contracts to be awarded through an open competitive process – that is, a process that is open to any person to submit a bid. They also require public sector purchasers to share material information with prospective bidders at the outset, and through particular communications channels; evaluate bids consistently and only against stated criteria; and publish information about successful bids. Also, new public procurement requirements require provincial governments to designate an impartial administrative or judicial authority to review challenges from bidders or prospective bidders (either in the first instance, or as an appeal body). Potential providers of healthcare goods and services should look to various online procurement portals for notices about pending and open competitive procurement processes.10

VIII MARKETING AND PROMOTION OF SERVICES

Communication with the public about healthcare services is regulated to ensure accuracy and maintain professionalism. Healthcare professionals may advertise for the purpose of providing information relevant to informed decision making. Provincial legislation and colleges' policies prescribe how professionals can market their services and describe their qualifications and education. Non-compliance may be considered professional misconduct.

Generally, legislation and policies prohibit:

  1. advertising that is false, misleading, or unprofessional;
  2. information that cannot be verified;
  3. claims of superiority, comparisons or guarantees;
  4. endorsements or testimonials; and
  5. reference to a specialisation unless certified by an official body.

It is generally acceptable to advertise fees for services that are not publicly funded; however, some policies restrict the use of promotional deals.

The prevalence of social media has raised new issues. The interactive nature of social media raises privacy concerns and the ease of sharing content can cause copyright infringement or plagiarism. Existing regulations apply to all means of communication, including print, oral or electronic. For example, prohibitions on inducements, such as coupons, continue to apply when using platforms such as mobile applications. Many regulatory bodies have developed specific social media use policies.

Advertisement by email and similar electronic means (e.g., SMS text) is also subject to privacy laws, as well as to Canada's anti-spam law, which requires a person sending an electronic marketing message of this kind to have prior consent or other authority to send that message. Canada's anti-spam law also requires the message to identify the sender, the sender's mailing address and other contact information, and to include an easy-to-use unsubscribe mechanism through which a person can request to no longer be sent electronic marketing messages.

IX FUTURE OUTLOOK AND NEW OPPORTUNITIES

Given Canada's ageing population, the high percentage of the country's GDP expended on healthcare, the comparatively poor health outcomes achieved11 and the challenges created by the single-payer healthcare system, it is likely that there will be both micro and macro changes to the healthcare landscape in the years to come. For example, the use of e-health and telemedicine represents a micro change that may create new opportunities. However, currently, legal and structural barriers to e-health and telemedicine exist; for example, there is no national framework for telemedicine.

Canadians today are accessing health information more easily and are continuing to proactively manage their own health, particularly through the use of products they can choose and use on their own, such as natural health products. Given the increased interest in these products, Health Canada engaged in extensive consultations beginning in 2016 to inform its new approach to regulating consumer health or 'self-care' products. Based on these consultation processes, Health Canada introduced the Self-Care Framework, which, among other things, aims to improve labelling of natural health products and, ultimately, expand the scope of Health Canada's oversight over consumer and self-care products. This Framework will be rolled out over three years, with the first of three phases being targeted to begin in spring 2020.

Recently, there has been an increasing focus on transparency about financial relationships within the healthcare system. Interest in such relationships stems from, among other things, the use of public dollars for payments within the healthcare system (e.g., payments from provincial health insurance plans to physicians), and the potential for conflicts of interest to arise where the relationship includes private sector payments to healthcare providers (e.g., payments from drug manufacturers to physicians). Legislative efforts, however, have been delayed. In 2017, Ontario was the first province to introduce legislation requiring public reporting of payments (the Health Sector Payment Transparency Act 2017), including those made by the private sector, to specified healthcare organisations and professionals. However, a new Ontario provincial government, on coming into power in 2018, reopened consultations and has delayed implementation indefinitely. British Columbia announced consultations on a 'health-sector transparency program' in mid-2018, which would, like the Health Sector Payment Transparency Act, compel the medical industry to report payments to healthcare organisations and professionals. No proposed legislation has been tabled.


Footnotes

1 Lynne Golding, David Rosenbaum, Daniel Fabiano, Kimberly Potter, Laurie Turner and Zohar Levy are partners, and Vanessa Mui and Sophie MacRae are associates, at Fasken Martineau DuMoulin LLP. The authors would like to thank Kathryn Beck, Rosario Cartagena, Heather Whiteside and Jacob Wagner for their assistance with the writing of this chapter.

2 As the distinction between a province and a territory is not important for the purposes of this chapter, all will be referred to herein as provinces.

3 Statistic provided by Statistics Canada.

4 The government of Canada provides direct healthcare services to First Nations people living on reserves, Inuit populations, serving members of the Canadian Forces, eligible veterans, inmates in federal penitentiaries and some refugee claimant groups.

5 Statistics provided by the Financial Accountability Office of Ontario and the Quebec government.

6 In 2019–2020, the provinces will receive, in the aggregate, approximately C$40.3 billion as part of the Canada Health Transfer.

7 For example, to be an eligible resident in Ontario (i.e., receive health insurance coverage in Ontario), an individual must, among other things, be present in Ontario for 153 days in any 12-month period.

8 Many provinces in Canada are moving away from a licensing model to a registration model with a focus on harm prevention. For the purposes of this chapter, the term 'registration' will be used to refer to both licensing and registration models.

9 For example, in Ontario, in 2017, legislative amendments were introduced to strengthen the penalties for healthcare professionals found to have sexually abused a patient.

10 See the webpage for the Canadian Free Trade Agreement for links to federal and provincial public procurement portals: https://www.cfta-alec.ca/doing-business/ 

11 OECD Health Statistics 2017, released 30 June 2017; Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care, The Commonwealth Fund, released 14 July 2017.