Under Lester Pearson's Liberal government, Canada's health care was expanded through the Medical Care Act, or Medicare to provide near universal coverage to all Canadians 'according to their need for such services and irrespective of their ability to pay'. ^[1].

Health care in Canada is delivered through a publicly funded health care system, which is mostly free at the point of use and has most services provided by private entities.^[2] It is guided by the provisions of the Canada Health Act of 1984.^[3] The government assures the quality of care through federal standards. The government does not participate in day-to-day care or collect any information about an individual's health, which remains confidential between a person and his or her physician. Canada's provincially based Medicare systems are cost-effective partly because of their administrative simplicity. In each province each doctor handles the insurance claim against the provincial insurer. There is no need for the person who accesses health care to be involved in billing and reclaim. Private insurance is only a minimal part of the overall health care system. Competitive practices such as advertising are kept to a minimum, thus maximizing the percentage of revenues that go directly towards care. In general, costs are paid through funding from income taxes, although British Columbia is the only province to impose a fixed monthly premium which is waived or reduced for those on low incomes.^[4] There are no deductibles on basic health care and co-pays are extremely low or non-existent (supplemental insurance such as Fair Pharmacare may have deductibles, depending on income). A health card is issued by the Provincial Ministry of Health to each individual who enrolls for the program and everyone receives the same level of care.^[5] There is no need for a variety of plans because virtually all essential basic care is covered, including maternity and infertility problems. Depending on the province, dental and vision care may not be covered but are often insured by employers through private companies. In some provinces, private supplemental plans are available for those who desire private rooms if they are hospitalized. Cosmetic surgery and some forms of elective surgery are not considered essential care and are generally not covered. These can be paid out-of-pocket or through private insurers. Health coverage is not affected by loss or change of jobs, as long as premiums are up to date, and there are no lifetime limits or exclusions for pre-existing conditions.

Pharmaceutical medications are covered by public funds for the elderly or indigent,^[6] or through employment-based private insurance. Drug prices are negotiated with suppliers by the federal government to control costs. Family physicians are chosen by individuals. If a patient wishes to see a specialist or is counseled to see a specialist, a referral can be made by a GP. Preventive care and early detection are considered important and yearly checkups are encouraged. Early detection not only extends life expectancy and quality of life, but cuts down overall costs.

Public opinion[link]

Canadians strongly support the health system's public rather than for-profit private basis, and a 2009 poll by Nanos Research found 86.2% of Canadians surveyed supported or strongly supported "public solutions to make our public health care stronger."^[7][8]

A 2009 Harris/Decima poll found 82% of Canadians preferred their healthcare system to the one in the United States, more than ten times as many as the 8% stating a preference for a US-style health care system for Canada^[9] while a Strategic Counsel survey in 2008 found 91% of Canadians preferring their healthcare system to that of the U.S.^[10][11] The same article mentioned that when asked about their own health care instead of the "health care system," more than half of Americans (51.3 percent) are very satisfied with their health care services, compared to only 41.5 percent of Canadians; a lower proportion of Americans are dissatisfied (6.8 percent) than Canadians (8.5 percent). Respondents then rated quality of service as excellent (36% Canada, 40% US), and being very satisfied with health care services (42% Canada, 53% US). When asked "overall the Canadian health care system was performing very well, fairly well, not very well or not at all?" 70% of Canadians rated their system as working either "well" or "very well".^{[citation needed]} A 2003 Gallup poll found only 25% of Americans are either "very" or "somewhat" satisfied with "the availability of affordable healthcare in the nation", versus 50% of those in the UK and 57% of Canadians. Those "very dissatisfied" made up 44% of Americans, 25% of respondents of Britons, and 17% of Canadians. The same report portrays a different story in terms of quality. When asked about the quality of medical care in their respective nations, 17% were strongly satisfied in the U.S. compared to 13% in Canada and 11% in Britain.^[12]

Economics[link]

Total Canadian health care expenditures in 1997 dollars from 1975 to 2009.^[13]

Canadian per capita health care spending by age group in 2007.^[14]

The amount Canadians spend on health care in 1997 dollars has increased every year between 1975 and 2009 from $39.7 billion to $137.3 billion or a more than doubling of per capita spending from $1,715 to $4089.^[15] In 2009 dollars spending is expected to reach $183.1 billion ( a more than five percent increase over the previous year ) or $5,452 per person.^[16] Most of this increase in health care costs has been covered by public funds.^[17] The greatest proportion of this money goes to hospitals ($51B), followed by pharmaceuticals ($30B), and physicians ($26B).^[16] Total spending in 2007 was equivalent to 10.1% of the gross domestic product which was slightly above the average for OECD countries, and below the 16.0% of GDP spent on health care in the United States.^[18] The proportion spent on hospitals and physicians has declined between 1975 and 2009 while the amount spent on pharmaceuticals has increased.^[19]

Of the three biggest health care expenses, the amount spent on pharmaceuticals has increased the most. In 1997 the total price of drugs surpassed that of doctors. In 1975 the three biggest health costs were hospitals ($5.5B/44.7%), physicians ($1.8B/15.1% ), and medications ($1.1B/8.8% ) while in 2007 the three biggest costs were hospitals ($45.4B/28.2% ), medications ($26.5B/16.5% ), and physicians ($21.5B/13.4% ).^[20]

In 2009, the government funded about 70% of Canadians' health care costs.^[21] This covered most hospital and physician cost while the dental and pharmaceutical costs were primarily paid for by individuals.^[21] This is slightly below the OECD average. Under the terms of the Canada Health Act, public funding is required to pay for medically necessary care, but only if it is delivered in hospitals or by physicians. There is considerable variation across the provinces/territories as to the extent to which such costs as out of hospital prescription medications, physical therapy, long-term care, dental care and ambulance services are covered.^[22]

Canada has a publicly funded medicare system, with most services provided by the private sector. Each province may opt out, though none currently do. Canada's system is known as a single payer system, where basic services are provided by private doctors (since 2002 they have been allowed to incorporate), with the entire fee paid for by the government at the same rate. Most government funding (94%) comes from the provincial level.^[14] Most family doctors receive a fee per visit. These rates are negotiated between the provincial governments and the province's medical associations, usually on an annual basis. Pharmaceutical costs are set at a global median by government price controls.

Hospital care is delivered by publicly funded hospitals in Canada. Most of the public hospitals, each of which are independent institutions incorporated under provincial Corporations Acts, are required by law to operate within their budget.^[23] Amalgamation of hospitals in the 1990s has reduced competition between hospitals. As the cost of patient care has increased, hospitals have been forced to cut costs or reduce services. Applying perspective (pharmacoeconomic) to analyze cost reduction, it has been shown that savings made by individual hospitals result in actual cost increases to the Provinces.^[24]

Health care costs per capita vary across Canada with Quebec ($4,891) and British Columbia ($5,254) at the lowest level and Alberta ($6,072) and Newfoundland ($5,970) at the highest.^[14] It is also the greatest at the extremes of age at a cost of $17,469 per capita in those older than 80 and $8,239 for those less than 1 year old in comparison to $3,809 for those between 1 and 64 years old in 2007.^[14]

History[link]

18th century[link]

Hospitals were initially places which cared for the poor; others were cared for at home. In Quebec (formerly known as New France and then as Lower Canada), a series of charitable institutions, many set up by Catholic religious orders, provided such care.^[25] As the country grew, hospitals grew with them. They tended to be not-for-profit, and were run by municipal governments, charitable organizations, and religious denominations (both Catholic and Protestant).^[26] These organizations tended to be at arm's length from government; they received subsidies from provincial governments to admit and treat all patients, regardless of their ability to pay. Dr. David Parker of the Maritimes was the first to operate using anesthetic. One of the first "modern" operations, the removal of a tumour, was performed by William Fraser Tolmie in British Columbia.

19th century[link]

The first medical schools were established in Lower Canada in the 1820s. These included the Montreal Medical Institution, which is the faculty of medicine at McGill University today; in the mid-1870s, Sir William Osler changed the face of medical school instruction throughout the West with the introduction of the hands-on approach. The College of Physicians and Surgeons of Upper Canada was established in 1839 and in 1869 was permanently incorporated. In 1834, William Kelly, a surgeon with the Royal Navy, introduced the idea of preventing the spread of disease via sanitation measures following epidemics of cholera. In 1871, female physicians Emily Howard Stowe and Jennie Kidd Trout won the right for women to be admitted to medical schools and granted licenses from the College of Physicians and Surgeons of Ontario. In 1883, Emily Stowe led the creation of the Ontario Medical College for Women, affiliated with the University of Toronto. In 1892, Dr. William Osler wrote the landmark text The Principles and Practice of Medicine, which dominated medical instruction in the West for the next 40 years. Around this time, a movement began that called for the improved health care for the poor, focusing mainly on sanitation and hygiene. This period saw important advances including the provision of safe drinking water to most of the population, public baths and beaches, and municipal garbage services to remove waste from the city. During this period, medical care was severely lacking for the poor and minorities such as First Nations^[27]

20th century[link]

The twentieth century saw the discovery of insulin by Frederick Banting and his colleagues, Charles Best, J.J.R. Macleod, and J.B. Collip^[28] in 1922. For this, Frederick Banting and J.J.R. Macleod of the University of Toronto won the 1923 Nobel Prize in Physiology and Medicine.^[29] Dr. Wilder Penfield, who discovered a successful surgical treatment for epilepsy called the "Montreal procedure", founded the Montreal Neurological Institute in 1934.

The early 20th century saw the first widespread calls for increased government involvement and the idea of a national health insurance system had considerable popularity. During the Great Depression calls for a public health system were widespread. Doctors who had long feared such an idea reconsidered hoping a government system could provide some stability as the depression had badly affected the medical community. However, governments had little money to enact the idea. In 1935, the United Farmers of Alberta passed a bill creating a provincial insurance program, but they lost office later that year and the Social Credit Party scrapped the plan due to the financial situation in the province. The next year a health insurance bill passed in British Columbia, but its implementation was halted over objections from doctors. William Lyon Mackenzie King promised to introduce such a scheme, but while he created the Department of Health he failed to introduce a national program.

The beginning of coverage[link]

Canadian health care spending for 1970 to 2007 compared with other nations

It was not until 1946 that the first Canadian province introduced near universal health coverage. Saskatchewan had long suffered a shortage of doctors, leading to the creation of municipal doctor programs in the early twentieth century in which a town would subsidize a doctor to practice there. Soon after, groups of communities joined to open union hospitals under a similar model. There had thus been a long history of government involvement in Saskatchewan health care, and a significant section of it was already controlled and paid for by the government. In 1946, the Co-operative Commonwealth Federation government in Saskatchewan passed the Saskatchewan Hospitalization Act, which guaranteed free hospital care for much of the population. Douglas had hoped to provide universal health care, but the province did not have the money.

In 1950, Alberta's Social Credit party also introduced a public health care plan. Alberta, however, created Medical Services (Alberta) Incorporated (MS(A)I) in 1948 to provide prepaid health services. This scheme eventually provided medical coverage to over 90% of the population.^[30]

In 1957, the majority Liberal government under Louis St. Laurent passed the Hospital Insurance and Diagnostic Services Act^[31] to fund 50% of the cost of such programs for any provincial government that adopted them. The HIDS Act outlined five conditions: public administration, comprehensiveness, universality, portability, and accessibility. These remain the pillars of the Canada Health Act.

By 1961, all ten provinces had agreed to start HIDS Act programs. In Saskatchewan, the act meant that half of their current program would now be paid for by the federal government. Premier Woodrow Lloyd decided to use this freed money to extend the health coverage to also include physicians. Despite the sharp disagreement of the Saskatchewan College of Physicians and Surgeons, Lloyd introduced the law in 1962 after defeating the Saskatchewan Doctors' Strike in July.

Medical Care Act[link]

The programs in Saskatchewan and Alberta proved a success and the federal government of Lester B. Pearson introduced the Medical Care Act in 1966 that extended the HIDS Act cost-sharing to allow each province to establish a universal health care plan -an initiative that was drafted and initiated by the Liberal party and supported by the New Democratic Party (NDP). It also set up the Medicare system. In 1984, the Canada Health Act was passed under a majority Liberal government, which prohibited user fees and extra billing by doctors. In 1999, the prime minister and most premiers reaffirmed in the Social Union Framework Agreement that they are committed to health care that has "comprehensiveness, universality, portability, public administration and accessibility."^[32]

Government involvement[link]

The various levels of government pay for about 70% of Canadians' health care, although this number has decreased somewhat in recent years.^[33] The Constitution Act, 1867 (formerly called the British North America Act, 1867, and still known informally as the BNA Act) did not give either the federal or provincial governments responsibility for health care, as it was then a minor concern. The Act did give the provinces responsibility for regulating hospitals, and the provinces claimed that their general responsibility for local and private matters encompassed health care. The federal government felt that the health of the population fell under the Peace, Order, and Good Government part of its responsibilities. This led to several decades of debate over jurisdiction that were not resolved until the 1930s. Eventually the Judicial Committee of the Privy Council JCPC decided that the administration and delivery of health care was a provincial concern, but that the federal government also had the responsibility of protecting the health and well-being of the population.

By far the largest government health program is Medicare, which is actually ten provincial programs, such as OHIP in Ontario, that are required to meet the general guidelines laid out in the federal Canada Health Act. Almost all government health spending goes through Medicare, but there are several smaller programs. The federal government directly administers health to groups such as the military, and inmates of federal prisons. They also provide some care to the Royal Canadian Mounted Police and veterans, but these groups mostly use the public system. Prior to 1966, Veterans Affairs Canada had a large health care network, but this was merged into the general system with the creation of Medicare. The largest group the federal government is directly responsible for is First Nations. Native peoples are a federal responsibility and the federal government guarantees complete coverage of their health needs. For the last 20 years and despite health care being a guaranteed right for First Nations due to the many treaties the government of Canada signed for access to First Nations lands and resources, the amount of coverage provided by the Federal government has diminished drastically for optometry, dentistry, and medicines. Status First Nations individuals only qualify for a set amount of visits to the optometrist and dentist, with a limited amount of coverage for glasses, eye exams, fillings, root canals, etc. For the most part First Nations people use the normal hospitals and the federal government then fully compensates the provincial government for the expense. The federal government also covers any user fees the province charges. The federal government maintains a network of clinics and health centres on Native Reserves. At the provincial level, there are also several much smaller health programs alongside Medicare. The largest of these is the health care costs paid by the worker's compensation system. Regardless of federal efforts, healthcare for First Nations has generally not been considered effective.^[34][35][36]

Despite being a provincial responsibility, the large health costs have long been partially funded by the federal government. The cost sharing agreement created by the HIDS Act and extended by the Medical Care Act was discontinued in 1977 and replaced by Established Programs Financing. This gave a bloc transfer to the provinces, giving them more flexibility but also reducing federal influence on the health system. In 1996, when faced with a large budget shortfall, the Liberal federal government merged the health transfers with the transfers for other social programs into the Canada Health and Social Transfer, and overall funding levels were cut. This placed considerable pressure on the provinces, and combined with population aging and the generally high rate of inflation in health costs, has caused problems with the system.

Private sector[link]

About 27.6% of Canadians' health care is paid for through the private sector. This mostly goes towards services not covered or only partially covered by Medicare, such as prescription drugs, dentistry and optometry. Some 75% of Canadians have some form of supplementary private health insurance; many of them receive it through their employers.^[37] There are also large private entities that can buy priority access to medical services in Canada, such as WCB in BC.

The Canadian system is for the most part publicly funded, yet most of the services are provided by private enterprises. Most doctors do not receive an annual salary, but receive a fee per visit or service.^[2] According to Dr. Albert Schumacher, former president of the Canadian Medical Association, an estimated 75 percent of Canadian health care services are delivered privately, but funded publicly.

"Frontline practitioners whether they're GPs or specialists by and large are not salaried. They're small hardware stores. Same thing with labs and radiology clinics ...The situation we are seeing now are more services around not being funded publicly but people having to pay for them, or their insurance companies. We have sort of a passive privatization."^[2]

"Although there are laws prohibiting or curtailing private health care in some provinces, they can be changed", according to a report in the New England Journal of Medicine.^[38][39] In June 2005, the Supreme Court of Canada ruled in Chaoulli v. Quebec (Attorney General) that Quebec's prohibition against private health insurance for medically necessary services laws violated the Quebec Charter of Human Rights and Freedoms, potentially opening the door to much more private sector participation in the health system. Justices Beverley McLachlin, Jack Major, Michel Bastarache and Marie Deschamps found for the majority. "Access to a waiting list is not access to health care", wrote Chief Justice Beverly McLachlin.

The Quebec and federal governments asked the high court to suspend its ruling for 18 months. Less than two months after its initial ruling, the court agreed to suspend its decision for 12 months, retroactive to June 9, 2005.^[40]

Physicians and medical organization[link]

Canada, like its North American neighbour the United States, has a ratio of practicing physicians to population that is below the OECD average ^[41] but a level of practicing nurses that is higher than either the U.S. or the OECD average.^[42]

Family physicians in Canada make an average of $202,000 a year (2006, before expenses).^[43] Alberta has the highest average salary of around $230,000, while Quebec has the lowest average annual salary at $165,000, arguably creating interprovincial competition for doctors and contributing to local shortages.^[43] In fact, the cost of living in Alberta is considerably higher than the cost of living in Quebec, so absolute income differentials can be massively misleading.

In 1991, the Ontario Medical Association agreed to become a province-wide closed shop, making the OMA union a monopoly. Critics argue that this measure has restricted the supply of doctors to guarantee its members' incomes.^[44]

In September 2008, the Ontario Medical Association and the Ontarian government agreed to a new four-year contract that will see doctors receive a 12.25% pay raise. The new agreement is expected to cost Ontarians an extra $1 billion. Referring to the agreement, Ontario premier Dalton McGuinty said,"One of the things that we've got to do, of course, is ensure that we're competitive ... to attract and keep doctors here in Ontario...".^[45]

In December 2008, the Society of Obstetricians and Gynaecologists of Canada reported a critical shortage of obstetricians and gynaecologists. The report stated that only 1,370 obstetricians were practicing in Canada and that number is expected to fall by at least one-third within five years. The society is asking the government to increase the number of medical school spots for obstetrics and gynecologists by 30 per cent a year for three years and also recommended rotating placements of doctors into smaller communities to encourage them to take up residence there.^[46]

Each province regulates its medical profession through a self-governing College of Physicians and Surgeons, which is responsible for licensing physicians, setting practice standards, and investigating and disciplining its members.

The national doctors association is called the Canadian Medical Association;^[47] it describes its mission as "To serve and unite the physicians of Canada and be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care. "^[48] Because health care is deemed to be under provincial/territorial jurisdiction, negotiations on behalf of physicians are conducted by provincial associations such as the Ontario Medical Association. The views of Canadian doctors have been mixed, particularly in their support for allowing parallel private financing. The history of Canadian physicians in the development of Medicare has been described by C. David Naylor.^[49] Since the passage of the 1984 Canada Health Act, the CMA itself has been a strong advocate of maintaining a strong publicly funded system, including lobbying the federal government to increase funding, and being a founding member of (and active participant in) the Health Action Lobby (HEAL).^[50]

However, there are internal disputes. In particular, some provincial medical associations have argued for permitting a larger private role. To some extent, this has been a reaction to strong cost control; CIHI estimates that 99% of physician expenditures in Canada come from public sector sources, and physicians—particularly those providing elective procedures who have been squeezed for operating room time—have accordingly looked for alternative revenue sources.

One indication of this internal dispute came when Dr. Brian Day of B.C. was elected CMA president in August 2007. Day is the owner of the largest private hospital in Canada and a vocal supporter of increasing private health care in Canada. The CMA presidency rotates among the provinces, with the provincial association electing a candidate who is customarily ratified by the CMA general meeting. Day's selection was sufficiently controversial that he was challenged—albeit unsuccessfully—by another physician. The newspaper story went on to note that "Day said he has never supported the privatization of health care in Canada, and accused his detractors of deliberately distorting his position." ^[51]

Criticisms[link]

Wait times[link]

Health Canada, a federal department, publishes a series of surveys of the health care system in Canada based on Canadians' first-hand experiences of the health care system.^[52]

Although life-threatening cases are dealt with immediately, some services needed are non-urgent and patients are seen at the next-available appointment in their local chosen facility.

The median wait time in Canada to see a special physician is a little over four weeks with 89.5% waiting fewer than 90 days.^[52]

The median wait time for diagnostic services such as MRI and CAT scans ^[53] is two weeks with 86.4% waiting fewer than 90 days.^[52]

The median wait time for surgery is four weeks with 82.2% waiting fewer than 90 days.^[52]

Another study by the Commonwealth Fund found that 57% of Canadians reported waiting 30 days (4 weeks) or more to see a specialist, broadly in line with the current official statistics. A quarter (24%) of all Canadians waited 4 hours or more in the emergency room.^[54]

Dr. Brian Day was once quoted as saying "This is a country in which dogs can get a hip replacement in under a week and in which humans can wait two-to-three years."^[55] Day gave no source for his two to three years claim. The Canadian Health Coalition has responded succinctly to Day's claims, pointing out that "access to veterinary care for animals is based on ability to pay. Dogs are put down if their owners can’t pay. Access to care should not be based on ability to pay." ^[56] Regional administrations of Medicare across Canada publish their own wait time data on the internet. For instance in British Columbia the wait time for a hip replacement is currently a little under ten weeks.^[57] The CHC is one of many groups across Canada calling for increased provincial and federal funding for medicare and an end to provincial funding cuts as solutions to unacceptable wait times.^[58] In a 2007 episode of ABC News's 20/20 titled "Sick in America", host John Stossel cited numerous examples of Canadians who did not get the health care that they needed.^[59] The Fraser Institute, a conservative think tank, claims to do its own research and found that treatment time from initial referral by a GP through consultation with a specialist to final treatment, across all specialties and all procedures (emergency, non-urgent, and elective), averaged 17.7 weeks in 2005.^[60] However, the report of the Fraser Institute is greatly at odds with the Canadian government's own 2007 report.^[61]

Criticisms have been laid during the administration of H1N1 shots in 2009, in parts of Canada, including Hamilton and Toronto. "Wait times for flu shots continued to be hours long yesterday [October 29] as Hamiltonians lined up for the only protection from H1N1 that public health can offer. Waits were about five hours at the clinic on the West Mountain, with 1,000 people in line. The Dundas clinic wasn't much better, with 700 waiting for a shot."^[62] "Hundreds of people who lined up in Toronto today were given slips of paper with a time on it so they could return for their vaccination without standing around for hours on end." ^[63]

Since 2002, the Canadian government has invested $5.5 billion to decrease wait times.^[64] In April 2007, Canadian Prime Minister Stephen Harper announced that all ten provinces and three territories would establish patient wait times guarantees by 2010. Canadians will be guaranteed timely access to health care in at least one of the following priority areas, prioritized by each province: cancer care, hip and knee replacement, cardiac care, diagnostic imaging, cataract surgeries or primary care.^[65]

Counter-criticism: some longer wait times can benefit patients[link]

It has been observed and found in data that the complete elimination of all waiting times is not ideal. When waiting lists arise through a prioritization process based on physician-determined medical urgency and the procedure's risk, (in contrast to patient's ability to pay or profitability for the physician), waiting lists can possibly help patients. It's been postulated that a system of immediate care can be detrimental for optimal patient outcomes due to avoidance of unnecessary or unproven surgery. An example is the Canadian province of British Columbia, where, according to surgeon Dr. Lawrence Burr, 15 heart patients died in 1990 while on a waiting list for heart surgery. According to Robin Hutchinson, senior medical consultant to the Health Ministry's heart program, had the waiting list not existed and all patients given instant access to the surgery, the expected number of fatalities would have been 22 due to the operation mortality rate at that time. Hutchison noted that the BC Medical Association's media campaign did not make reference to these comparative statistics and only focused on deaths during waiting for surgery.^[66]

Since, ideally, waiting lists prioritize higher-risk patients to receive surgery ahead of those with lower risks, this helps reduce overall patient mortality. Consequently, a wealthy or highly insured patient in a system based on profit or ability to pay (as in the U.S.) may be pushed into surgery or other procedures more quickly, with a result in higher morbidity or mortality risk. This is in addition to the better-understood phenomenon in which lower-income, uninsured, or under-insured patients have their care denied or delayed, also resulting in worse health care.^[67]

Restrictions on privately funded health care[link]

The Canada Health Act, which sets the conditions with which provincial/territorial health insurance plans must comply if they wish to receive their full transfer payments from the federal government, does not allow charges to insured persons for insured services (defined as medically necessary care provided in hospitals or by physicians). Most provinces have responded through various prohibitions on such payments. This does not constitute a ban on privately funded care; indeed, about 30% of Canadian health expenditures come from private sources, both insurance and out-of-pocket payments.^[68] The Canada Health Act does not address delivery. Private clinics are therefore permitted, albeit subject to provincial/territorial regulations, but they cannot charge above the agreed-upon fee schedule unless they are treating non-insured persons (which may include those eligible under automobile insurance or worker's compensation, in addition to those who are not Canadian residents), or providing non-insured services. This provision has been controversial among those seeking a greater role for private funding.

In 2006, the Government of British Columbia threatened to shut down one private clinic because it was planning to start accepting private payments from patients.^[69]

Governments have responded through wait time strategies, discussed above, which attempt to ensure that patients will receive high-quality, necessary services in a timely manner. Nonetheless, the debate continues.

Cross-border health care[link]

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The border between Canada and the United States represents a boundary line for medical tourism, in which a country's residents travel elsewhere to seek health care that is more available or affordable.

Canadians visiting the US to receive health care[link]

Some residents of Canada travel to the United States because it provides the nearest facility for their needs. Some do so on quality grounds or because of easier access. A study by Barer, et al., indicates that the majority of Canadians who seek health care in the U.S. are already there for other reasons, including business travel or vacations. A smaller proportion seek care in the U.S. for reasons of confidentiality, including abortions, mental illness, substance abuse, and other problems that they may not wish to divulge to their local physician, family, or employer.

• Canadians offered free care in the US paid by the Canadian government have sometimes declined it. In 1990 the British Columbia Medical Association ran radio ads asking, "What's the longest you'd wait in line at a bank before getting really annoyed? Five minutes? Ten minutes? What if you needed a heart operation?" Following this, the government responded, as summarized by Robin Hutchinson, senior medical consultant for the health ministry's heart program. Despite the medically questionable nature of heart bypass for milder cases of chest pain and follow-up studies showing heart bypass recipients were only 25-40% more likely to be relieved of chest pain than people who stay on heart medicine, the "public outcry" following the ads led the government to take action:

"'We did a deal with the University of Washington at Seattle' said Hutchinson.. to take 50 bypass cases at $18,000 per head, almost $3,000 higher than the cost in Vancouver, with all the money [paid by] the province..In theory, the Seattle operations promised to take the heat off the Ministry of Health until a fourth heart surgery unit opened in the Vancouver suburb of New Westminster. If the first batch of Seattle bypasses went smoothly..then the government planned to buy three or four more 50-head blocks. But four weeks after announcing the plan, health administrators had to admit they were stumped. 'As of now..we've have nine people sign up. The opposition party, the press, everybody's making a big stink about our waiting lists. And we've got [only] nine people signed up! The surgeons ask their patients and they say, "I'd rather wait", We thought we could get maybe two hundred and fifty done down in Seattle..but if nobody wants to go to Seattle, we're stuck,'".^[67]

• In a Canadian National Population Health Survey of 17,276 Canadian residents, it was reported that only 0.5% sought medical care in the US in the previous year. Of these, less than a quarter had traveled to the U.S. expressly to get that care.^[70]
• A 2002 study by Katz, Cardiff, et al., reported the number of Canadians using U.S. services to be "barely detectible relative to the use of care by Canadians at home" and that the results "do not support the widespread perception that Canadian residents seek care extensively in the United States."^[71]
• According to a September 14, 2007, article from CTV News, Canadian Liberal MP Belinda Stronach went to the United States for breast cancer surgery in June 2007. Stronach's spokesperson Greg MacEachern was quoted in the article saying that the US was the best place to have this type of surgery done. Stronach paid for the surgery out of her own pocket.^[72] Prior to this incident, Stronach had stated in an interview that she was against two-tier health care.^[73]
• When Robert Bourassa, the premier of Quebec, needed cancer treatment, he went to the US to get it.^[74]
• In 2007, it was reported that Canada sent scores of pregnant women to the US to give birth.^[75] In 2007 a woman from Calgary who was pregnant with quadruplets was sent to Great Falls, Montana to give birth. An article on this incident states there were no Canadian hospitals with enough neo-natal intensive beds to accommodate the extremely rare quadruple birth.^[76]
• A January 19, 2008, article in The Globe and Mail states, "More than 150 critically ill Canadians – many with life-threatening cerebral hemorrhages – have been rushed to the United States since the spring of 2006 because they could not obtain intensive-care beds here. Before patients with bleeding in or outside the brain have been whisked through U.S. operating-room doors, some have languished for as long as eight hours in Canadian emergency wards while health-care workers scrambled to locate care." ^[77]
• In 2010, Newfoundland and Labrador Premier Danny Williams traveled to the US for heart surgery.^[78]

In 2005 Shona Holmes of Waterdown, Ontario, traveled to the Mayo Clinic after deciding she couldn't afford to wait for appointments with specialists through the Ontario health care system.^[79][80] She has characterized her condition as an emergency, said she was losing her sight, and portrayed her condition as life-threatening brain cancer. OHIP did not reimburse her for her medical expenses. In 2007 she joined a lawsuit to force the Ontario government to reimburse patients who feel they had to travel outside of Canada for timely, life-saving medical treatment. In July 2009 Holmes agreed to appear in television ads broadcast in the United States warning Americans of the dangers of adopting a Canadian style health care system. After her ad appeared critics pointed out discrepancies in her story, including that Rathke's cleft cyst, the condition she was treated for, was not a form of cancer, and was not life-threatening.^[81][82] In fact, the mortality rate for patients with a Rathke's cleft cyst is zero percent. ^[83]

US citizens visiting Canada to receive health care[link]

On the other hand, some US citizens travel to Canada for health-care related reasons:

• Many US citizens purchase prescription drugs from Canada, either over the Internet or by traveling there to buy them in person, because prescription drug prices in Canada are substantially lower than prescription drug prices in the United States; this cross-border purchasing has been estimated at $1 billion annually.^[84]
• Because medical marijuana is legal in Canada but illegal in most of the US, many US citizens suffering from cancer, AIDS, multiple sclerosis, and glaucoma have traveled to Canada for medical treatment. One of those is Steve Kubby, the Libertarian Party's 1998 candidate for governor of California, who is suffering from adrenal cancer.^[85] Recent legal changes such as Proposition 215 may decrease this type of medical tourism from California only.
• Sarah Palin, in an appearance in Calgary, told her audience that her family once used the Canadian health-care system,^[86] before the Canada Health Act although she says it was in the 60s, when the Canadian healthcare system was beginning to reform.

Comparison to other countries[link]

The Canadian health care system is often compared to the US system. In 2007 a systematic review concluded that outcomes may be superior in Canada versus the United States.^[87] The US system spends the most in the world per capita, and was ranked 37th in the world by the World Health Organization in 2000, while Canada's health system was ranked 30th. The relatively low Canadian WHO ranking has been criticized by some^[who?] for its choice of ranking criteria and statistical methods, and the WHO is currently revising its methodology and withholding new rankings until the issues are addressed.^[88][89]

Canada spent approximately 10.0% of GDP on health care in 2006, more than one percentage point higher than the average of 8.9% in OECD countries.^[90] According to the Canadian Institute for Health Information, spending is expected to reach $160 billion, or 10.6% of GDP, in 2007.^[91] This translates to $4,867 per person.

Most health statistics in Canada are at or above the G8 average.^[92] Direct comparisons of health statistics across nations is complex. The OECD collects comparative statistics, and has published brief country profiles.^[93][94][95]

See also[link]

Canada portal

	Book: Canada
Wikipedia books are collections of articles that can be downloaded or ordered in print.

• Canada Health Act
• Canada Health Transfer
• Canada Health and Social Transfer
• Canada's Health Care providers, 2007
• Canadian and American health care systems compared
• Chronic disease in Northern Ontario
• Health care compared - tabular comparisons of the US, Canada, and other countries not shown above.
• Health Evidence Network of Canada
• Indian Health Transfer Policy (Canada)
• Medicare (Canada)
• Royal Commission on the Future of Health Care in Canada
• Suicide in Canada

References[link]

Bibliography

External links[link]

• Canadian Federalism and Public Health Care: The Evolution of Federal-Provincial Relations | Mapleleafweb.com
• CBC Digital Archives — The Birth of Medicare
• Canadian Health Services Research Foundation
• Data from the Canadian Institute for Health Information
  • National Health Expenditure Database
  • Exploring the 70/30 Split: How Canada's Health Care System Is Financed
  • National Physician Database

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Canada
Coat of arms of Canada Flag Coat of arms
Motto: A Mari Usque Ad Mare  (Latin) "From Sea to Sea"
Anthem: "O Canada" Royal anthem: "God Save the Queen"[1][2]
Capital		Ottawa 45°24′N 75°40′W / 45.4°N 75.667°W / 45.4; -75.667
Largest city		Toronto
Official language(s)		English and French
Recognised regional languages		Chipewyan, Cree, Gwich’in, Inuinnaqtun, Inuktitut, Inuvialuktun, Slavey (North and South) and Tłįchǫ[3]
Demonym		Canadian
Government		Federal parliamentary democracy and constitutional monarchy[4]
-	Monarch	Elizabeth II
-	Governor General	David Johnston
-	Prime Minister	Stephen Harper
-	Chief Justice	Beverley McLachlin
Legislature		Parliament
-	Upper house	Senate
-	Lower house	House of Commons
Establishment		from the United Kingdom
-	Constitution Act, 1867	July 1, 1867
-	Statute of Westminster	December 11, 1931
-	Canada Act	April 17, 1982
Area
-	Total	9,984,670 km2 (2nd) 3,854,085 sq mi
-	Water (%)	8.92 (891,163 km2/344,080 mi2)
Population
-	2012 estimate	34,839,000[5] (35th)
-	2011 census	33,476,688[6]
-	Density	3.41/km2 (228th) 8.3/sq mi
GDP (PPP)		2011 estimate
-	Total	$1.396 trillion[7] (14th)
-	Per capita	$40,541[7] (12th)
GDP (nominal)		2011 estimate
-	Total	$1.736 trillion (10th)
-	Per capita	$50,436[7] (9th)
Gini (2005)		32.1[8] (medium)
HDI (2011)		0.908[9] (very high) (6th)
Currency		Canadian dollar ($) (CAD)
Time zone		(UTC−3.5 to −8)
-	Summer (DST)	(UTC−2.5 to −7)
Date formats		dd-mm-yyyy, mm-dd-yyyy, and yyyy-mm-dd (CE)
Drives on the		Right
ISO 3166 code		CA
Internet TLD		.ca
Calling code		+1

Canada ( /ˈkænədə/) is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean. Spanning over 9,900,000 km² (3,800,000 sq mi), Canada is the world's second-largest country by total area, and its common border with the United States is the longest land border in the world.

The land that is now Canada has been inhabited for millennia by various Aboriginal peoples. Beginning in the late 15th century, British and French colonial expeditions explored, and later settled, along the region's Atlantic coast. France ceded nearly all of its colonies in North America in 1763 after the Seven Years' War. In 1867, with the union of three British North American colonies through Confederation, Canada was formed as a federal dominion of four provinces. This began an accretion of provinces and territories and a process of increasing autonomy; the Canada Act 1982 severed the vestiges of legal dependence on Britain.

Canada is a federal state that is governed as a parliamentary democracy and a constitutional monarchy, with Queen Elizabeth II as its head of state. The country is officially bilingual at the federal level. Canada's diversified economy is one of the world's largest, and is reliant upon its abundant natural resources and upon trade – particularly with the United States, with which Canada has had a long and complex relationship. It is a member of the G7, G8, G20, NATO, OECD, WTO, Commonwealth of Nations, Francophonie, OAS, APEC, and United Nations.

Etymology[link]

The name Canada comes from the St. Lawrence Iroquoian word kanata, meaning "village" or "settlement".^[10] In 1535, indigenous inhabitants of the present-day Quebec City region used the word to direct French explorer Jacques Cartier to the village of Stadacona.^[11] Cartier later used the word Canada to refer not only to that particular village, but also the entire area subject to Donnacona (the chief at Stadacona); by 1545, European books and maps had begun referring to this region as Canada.^[11]

In the 17th and early 18th centuries, "Canada" referred to the part of New France that lay along the St. Lawrence River and the northern shores of the Great Lakes. The area was later split into two British colonies, Upper Canada and Lower Canada. They were reunified as the Province of Canada in 1841.^[12]

Upon Confederation in 1867, Canada was adopted as the legal name for the new country, and the word Dominion was conferred as the country's title.^[13] However, as Canada asserted its political autonomy from the United Kingdom, the federal government increasingly used simply Canada on state documents and treaties, a change that was reflected in the renaming of the national holiday from Dominion Day to Canada Day in 1982.^[14]

History[link]

Aboriginal peoples[link]

Archaeological studies and analyses of DNA haplogroups have indicated a human presence in the northern Yukon region from 24,500 BC, and in southern Ontario from 7500 BC.^[15][16][17] The Paleo-Indian archaeological sites at Old Crow Flats and Bluefish Caves are two of the oldest sites of human habitation in Canada.^[18][19][20] The characteristics of Canadian Aboriginal societies included permanent settlements, agriculture, complex societal hierarchies, and trading networks.^[21][22] Some of these cultures had collapsed by the time European explorers arrived in the late 15th and early 16th centuries, and have only been discovered through archaeological investigations.^[23]

The aboriginal population is estimated to have been between 200,000^[24] and two million in the late 15th century,^[25] with a figure of 500,000 accepted by Canada's Royal Commission on Aboriginal Health.^[26] As a consequence of the European colonization, Canada's aboriginal peoples suffered from repeated outbreaks of newly introduced infectious diseases such as influenza, measles, and smallpox (to which they had no natural immunity), resulting in a forty- to eighty-percent population decrease in the centuries after the European arrival.^[24] Aboriginal peoples in present-day Canada include the First Nations,^[27] Inuit,^[28] and Métis.^[29] The Métis are a mixed-blood people who originated in the mid-17th century when First Nations and Inuit people married European settlers.^[30] In general, the Inuit had more limited interaction with European settlers during the colonization period.^[31]

European colonization[link]

Benjamin West's The Death of General Wolfe (1771) dramatizes James Wolfe's death during the Battle of the Plains of Abraham at Quebec in 1759.

The first known attempt at European colonization began when Norsemen settled briefly at L'Anse aux Meadows in Newfoundland around 1000 AD.^[32] No further European exploration occurred until 1497, when Italian seafarer John Cabot explored Canada's Atlantic coast for England.^[33] Basque and Portuguese mariners established seasonal whaling and fishing outposts along the Atlantic coast in the early 16th century.^[34] In 1534, French explorer Jacques Cartier explored the St. Lawrence River, where on July 24 he planted a 10-metre (33 ft) cross bearing the words "Long Live the King of France", and took possession of the territory in the name of King Francis I of France.^[35]

In 1583, Sir Humphrey Gilbert claimed St. John's, Newfoundland, as the first North American English colony by the royal prerogative of Queen Elizabeth I.^[36] French explorer Samuel de Champlain arrived in 1603, and established the first permanent European settlements at Port Royal in 1605 and Quebec City in 1608. Among the French colonists of New France, Canadiens extensively settled the St. Lawrence River valley and Acadians settled the present-day Maritimes, while fur traders and Catholic missionaries explored the Great Lakes, Hudson Bay, and the Mississippi watershed to Louisiana. The Beaver Wars broke out in the mid-17th century over control of the North American fur trade.^[37]

The English established additional colonies in Cupids and Ferryland, Newfoundland, beginning in 1610. The Thirteen Colonies were founded to the south soon after.^[34] A series of four French and Indian Wars erupted between 1689 and 1763.^[38] Mainland Nova Scotia came under British rule with the 1713 Treaty of Utrecht; the Treaty of Paris (1763) ceded Canada and most of New France to Britain after the Seven Years' War.^[39]

The Royal Proclamation of 1763 created the Province of Quebec out of New France, and annexed Cape Breton Island to Nova Scotia.^[14] St. John's Island (now Prince Edward Island) became a separate colony in 1769.^[40] To avert conflict in Quebec, the British passed the Quebec Act of 1774, expanding Quebec's territory to the Great Lakes and Ohio Valley. It re-established the French language, Catholic faith, and French civil law there. This angered many residents of the Thirteen Colonies, fuelling anti-British sentiment in the years prior to the 1775 outbreak of the American Revolution.^[14]

The 1783 Treaty of Paris recognized American independence and ceded territories south of the Great Lakes to the United States. New Brunswick was split from Nova Scotia as part of a reorganization of Loyalist settlements in the Maritimes. To accommodate English-speaking Loyalists in Quebec, the Constitutional Act of 1791 divided the province into French-speaking Lower Canada (later Quebec) and English-speaking Upper Canada (later Ontario), granting each its own elected legislative assembly.^[41]

Robert Harris's Fathers of Confederation (1884), an amalgamation of the Charlottetown and Quebec conferences of 1864.^[42]

The Canadas were the main front in the War of 1812 between the United States and Britain. Following the war, large-scale immigration to Canada from Britain and Ireland began in 1815.^[25] Between 1825 and 1846, 626,628 European immigrants reportedly landed at Canadian ports.^[43] Between one-quarter and one-third of all Europeans who immigrated to Canada before 1891 died of infectious diseases.^[24]

The desire for responsible government resulted in the abortive Rebellions of 1837. The Durham Report subsequently recommended responsible government and the assimilation of French Canadians into English culture.^[14] The Act of Union 1840 merged The Canadas into a united Province of Canada. Responsible government was established for all British North American provinces by 1849.^[44] The signing of the Oregon Treaty by Britain and the United States in 1846 ended the Oregon boundary dispute, extending the border westward along the 49th parallel. This paved the way for British colonies on Vancouver Island (1849) and in British Columbia (1858).^[45]

Confederation and expansion[link]

An animated map showing the growth and change of Canada's provinces and territories since Confederation in 1867.

Following several constitutional conferences, the 1867 Constitution Act officially proclaimed Canadian Confederation on July 1, 1867, initially with four provinces – Ontario, Quebec, Nova Scotia, and New Brunswick.^[46][47][48] Canada assumed control of Rupert's Land and the North-Western Territory to form the Northwest Territories, where the Métis' grievances ignited the Red River Rebellion and the creation of the province of Manitoba in July 1870.^[49] British Columbia and Vancouver Island (which had been united in 1866) joined the Confederation in 1871, while Prince Edward Island joined in 1873.^[50] Prime Minister John A. Macdonald and his Conservative government established a National Policy of tariffs to protect the nascent Canadian manufacturing industries.^[48]

To open the West, the government sponsored the construction of three transcontinental railways (including the Canadian Pacific Railway), opened the prairies to settlement with the Dominion Lands Act, and established the North-West Mounted Police to assert its authority over this territory.^[51][52] In 1898, during the Klondike Gold Rush in the Northwest Territories, the Canadian government created the Yukon Territory. Under the Liberal Prime Minister Wilfrid Laurier, continental European immigrants settled the prairies, and Alberta and Saskatchewan became provinces in 1905.^[50]

Early 20th century[link]

Canadian soldiers and Mark II tank at the Battle of Vimy Ridge in 1917.

Because Britain still maintained control of Canada's foreign affairs under the Confederation Act, its declaration of war in 1914 automatically brought Canada into World War I. Volunteers sent to the Western Front later became part of the Canadian Corps. The Corps played a substantial role in the Battle of Vimy Ridge and other major engagements of the war.^[53] Out of approximately 625,000 Canadians who served in World War I, around 60,000 were killed and another 173,000 were wounded.^[54] The Conscription Crisis of 1917 erupted when conservative Prime Minister Robert Borden brought in compulsory military service over the objections of French-speaking Quebecers. In 1919, Canada joined the League of Nations independently of Britain,^[53] and the 1931 Statute of Westminster affirmed Canada's independence.^[4]

The Great Depression of the early 1930s brought great economic hardship to Canada. In response to the downturn, the Co-operative Commonwealth Federation (CCF) in Saskatchewan introduced many elements of a welfare state (as pioneered by Tommy Douglas) in the 1940s and 1950s.^[55] Canada declared war on Germany independently during World War II under Liberal Prime Minister William Lyon Mackenzie King, three days after Britain. The first Canadian Army units arrived in Britain in December 1939.^[53]

Canadian troops played important roles in many key battles of the war, including the failed 1942 Dieppe Raid, the Allied invasion of Italy, the Normandy landings, the Battle of Normandy, and the Battle of the Scheldt in 1944.^[53] Canada provided asylum for the monarchy of the Netherlands while that country was occupied, and is credited by the Netherlands for major contributions to its liberation from Nazi Germany.^[56] The Canadian economy boomed during the war as its industries manufactured military materiel for Canada, Britain, China, and the Soviet Union.^[53] Despite another Conscription Crisis in Quebec, Canada finished the war with a large army and strong economy.^[57]

Modern times[link]

At Rideau Hall, Governor General the Viscount Alexander of Tunis (centre) receives the bill finalizing the union of Newfoundland and Canada on March 31, 1949.

The Dominion of Newfoundland (now Newfoundland and Labrador) was unified with Canada in 1949.^[58] Canada's post-war economic growth, combined with the policies of successive Liberal governments, led to the emergence of a new Canadian identity, marked by the adoption of the current Maple Leaf Flag in 1965,^[59] the implementation of official bilingualism (English and French) in 1969,^[60] and the institution of official multiculturalism in 1971.^[61] Socially democratic programs were also instituted, such as Medicare, the Canada Pension Plan, and Canada Student Loans, though provincial governments, particularly Quebec and Alberta, opposed many of these as incursions into their jurisdictions.^[62] Finally, another series of constitutional conferences resulted in the 1982 patriation of Canada's constitution from the United Kingdom, concurrent with the creation of the Canadian Charter of Rights and Freedoms.^[63] In 1999, Nunavut became Canada's third territory after a series of negotiations with the federal government.^[64]

At the same time, Quebec underwent profound social and economic changes through the Quiet Revolution of the 1960s, giving birth to a modern nationalist movement. The radical Front de libération du Québec (FLQ) ignited the October Crisis in 1970,^[65] and the sovereignist Parti Québécois was elected in 1976, organizing an unsuccessful referendum on sovereignty-association in 1980. Attempts to accommodate Quebec nationalism constitutionally through the Meech Lake Accord failed in 1990.^[66] This led to the formation of the Bloc Québécois in Quebec and the invigoration of the Reform Party of Canada in the West.^[67][68] A second referendum followed in 1995, in which sovereignty was rejected by a slimmer margin of just 50.6 to 49.4 percent. In 1997, the Supreme Court ruled that unilateral secession by a province would be unconstitutional, and the Clarity Act was passed by parliament, outlining the terms of a negotiated departure from Confederation.^[66]

In addition to the issues of Quebec sovereignty, a number of crises shook Canadian society in the late 1980s and early 1990s. These included the explosion of Air India Flight 182 in 1985, the largest mass murder in Canadian history;^[69] the École Polytechnique massacre in 1989, a university shooting targeting female students;^[70] and the Oka Crisis of 1990,^[71] the first of a number of violent confrontations between the government and Aboriginal groups.^[72] Canada also joined the Gulf War in 1990 as part of a US-led coalition force, and was active in several peacekeeping missions in the late 1990s.^[73] Canada sent troops to Afghanistan in 2001, but declined to send forces to Iraq when the US invaded in 2003.^[74] In 2011, Canadian forces participated in the NATO-led intervention into the Libyan civil war.^[75]

Geography[link]

A satellite composite image of Canada. Boreal forests prevail on the rocky Canadian Shield, while ice and tundra are prominent in the Arctic. Glaciers are visible in the Canadian Rockies and Coast Mountains. The flat and fertile prairies facilitate agriculture. The Great Lakes feed the St. Lawrence River in the southeast, where lowlands host much of Canada's population.

Canada occupies a major northern portion of North America, sharing land borders with the contiguous United States to the south and the US state of Alaska to the northwest. Canada stretches from the Atlantic Ocean in the east to the Pacific Ocean in the west; to the north lies the Arctic Ocean.^[76][77] Greenland is to the northeast, while Saint Pierre and Miquelon is south of Newfoundland.

By total area (including its waters), Canada is the second-largest country in the world, after Russia. By land area alone, Canada ranks fourth.^[77] The country lies between latitudes 41° and 84°N, and longitudes 52° and 141°W.

Since 1925, Canada has claimed the portion of the Arctic between 60° and 141°W longitude,^[78] but this claim is not universally recognized. Canada is home to the world's northernmost settlement, Canadian Forces Station Alert, on the northern tip of Ellesmere Island – latitude 82.5°N – which lies 817 kilometres (508 mi) from the North Pole.^[79] Much of the Canadian Arctic is covered by ice and permafrost. Canada has the longest coastline in the world, with a total length of 202,080 kilometres (125,570 mi);^[77] additionally, its border with the United States is the world's longest land border, stretching 8,891 kilometres (5,525 mi).^[80]

The Horseshoe Falls in Niagara Falls, Ontario, is one of the world's most voluminous waterfalls.^[81]

Since the end of the last glacial period, Canada has consisted of eight distinct forest regions, including extensive boreal forest on the Canadian Shield.^[82] Canada has around 31,700 large lakes,^[83] more than any other country, containing much of the world's fresh water.^[84] There are also fresh-water glaciers in the Canadian Rockies and the Coast Mountains. Canada is geologically active, having many earthquakes and potentially active volcanoes, notably Mount Meager, Mount Garibaldi, Mount Cayley, and the Mount Edziza volcanic complex.^[85] The volcanic eruption of the Tseax Cone in 1775 was among Canada's worst natural disasters, killing 2,000 Nisga'a people and destroying their village in the Nass River valley of northern British Columbia. The eruption produced a 22.5-kilometre (14.0 mi) lava flow, and, according to Nisga'a legend, blocked the flow of the Nass River.^[86]

Canada's population density, at 3.3 inhabitants per square kilometre (8.5 /sq mi), is among the lowest in the world. The most densely populated part of the country is the Quebec City – Windsor Corridor, situated in Southern Quebec and Southern Ontario along the Great Lakes and the St. Lawrence River.^[87]

Average winter and summer high temperatures across Canada vary from region to region. Winters can be harsh in many parts of the country, particularly in the interior and Prairie provinces, which experience a continental climate, where daily average temperatures are near −15 °C (5 °F), but can drop below −40 °C (−40 °F) with severe wind chills.^[88] In noncoastal regions, snow can cover the ground for almost six months of the year, while in parts of the north snow can persist year-round. Coastal British Columbia has a temperate climate, with a mild and rainy winter. On the east and west coasts, average high temperatures are generally in the low 20s °C (70s °F), while between the coasts, the average summer high temperature ranges from 25 to 30 °C (77 to 86 °F), with temperatures in some interior locations occasionally exceeding 40 °C (104 °F).^[89]

Government and politics[link]

Parliament Hill in Canada's capital city, Ottawa

Canada has a parliamentary system within the context of a constitutional monarchy, the monarchy of Canada being the foundation of the executive, legislative, and judicial branches.^{[90][91][92][93]} The sovereign is Queen Elizabeth II, who also serves as head of state of 15 other Commonwealth countries and each of Canada's ten provinces and resides predominantly in the United Kingdom. As such, the Queen's representative, the Governor General of Canada (presently David Lloyd Johnston), carries out most of the federal royal duties in Canada.^[94][95]

The direct participation of the royal and viceroyal figures in areas of governance is limited;^[92][96][97] in practice, their use of the executive powers is directed by the Cabinet, a committee of ministers of the Crown responsible to the elected House of Commons and chosen and headed by the Prime Minister of Canada (presently Stephen Harper),^[98] the head of government, though the governor general or monarch may in certain crisis situations exercise their power without ministerial advice.^[96] To ensure the stability of government, the governor general will usually appoint as prime minister the person who is the current leader of the political party that can obtain the confidence of a plurality in the House of Commons.^[99] The Prime Minister's Office (PMO) is thus one of the most powerful institutions in government, initiating most legislation for parliamentary approval and selecting for appointment by the Crown, besides the aforementioned, the governor general, lieutenant governors, senators, federal court judges, and heads of Crown corporations and government agencies.^[96] The leader of the party with the second-most seats usually becomes the Leader of Her Majesty's Loyal Opposition (presently Thomas Mulcair) and is part of an adversarial parliamentary system intended to keep the government in check.^[100]

The Senate chamber within the Centre Block on Parliament Hill

Each of the 308 Members of Parliament in the House of Commons is elected by simple plurality in an electoral district or riding. General elections must be called by the governor general, on the advice of the prime minister, within four years of the previous election, or may be triggered by the government losing a confidence vote in the House.^[101] The 105 members of the Senate, whose seats are apportioned on a regional basis, serve until age 75.^[102] Five parties had representatives elected to the federal parliament in the 2011 elections: the Conservative Party of Canada (governing party), the New Democratic Party (the Official Opposition), the Liberal Party of Canada, the Bloc Québécois, and the Green Party of Canada. The list of historical parties with elected representation is substantial.

Canada's federal structure divides government responsibilities between the federal government and the ten provinces. Provincial legislatures are unicameral and operate in parliamentary fashion similar to the House of Commons.^[97] Canada's three territories also have legislatures, but these are not sovereign and have fewer constitutional responsibilities than the provinces.^[103] The territorial legislatures also differ structurally from their provincial counterparts.^[104]

Law[link]

The Constitution of Canada is the supreme law of the country, and consists of written text and unwritten conventions. The Constitution Act, 1867 (known as the British North America Act prior to 1982) affirmed governance based on parliamentary precedent and divided powers between the federal and provincial governments; the Statute of Westminster 1931 granted full autonomy; and the Constitution Act, 1982, ended all legislative ties to the UK, added a constitutional amending formula, and added the Canadian Charter of Rights and Freedoms, which guarantees basic rights and freedoms that usually cannot be overridden by any government – though a notwithstanding clause allows the federal parliament and provincial legislatures to override certain sections of the Charter for a period of five years.^[105]

The Indian Chiefs Medal, presented to commemorate the Numbered Treaties

Although not without conflict, European Canadians' early interactions with First Nations and Inuit populations were relatively peaceful. The Crown and Aboriginal peoples began interactions during the European colonialization period. Numbered Treaties, the Indian Act, the Constitution Act of 1982, and case laws were established.^[106] A series of eleven treaties were signed between Aboriginals in Canada and the reigning Monarch of Canada from 1871 to 1921.^[107] These treaties are agreements with the Government of Canada administered by Canadian Aboriginal law and overseen by the Minister of Indian Affairs and Northern Development. The role of the treaties was reaffirmed by Section Thirty-five of the Constitution Act, 1982, which "recognizes and affirms existing Aboriginal and treaty rights".^[106] These rights may include provision of services such as health care, and exemption from taxation.^[108] The legal and policy framework within which Canada and First Nations operate was further formalized in 2005, through the First Nations–Federal Crown Political Accord.^[106]

The Supreme Court of Canada in Ottawa, west of Parliament Hill

Canada's judiciary plays an important role in interpreting laws and has the power to strike down laws that violate the Constitution. The Supreme Court of Canada is the highest court and final arbiter and has been led by the Chief Justice Beverley McLachlin, P.C. (the first female Chief Justice) since 2000.^[109] Its nine members are appointed by the governor general on the advice of the Prime Minister and Minister of Justice. All judges at the superior and appellate levels are appointed after consultation with nongovernmental legal bodies. The federal cabinet also appoints justices to superior courts at the provincial and territorial levels.^[110]

Common law prevails everywhere except in Quebec, where civil law predominates. Criminal law is solely a federal responsibility and is uniform throughout Canada.^[111] Law enforcement, including criminal courts, is officially a provincial responsibility, conducted by provincial police forces.^[112] However, in most rural areas and some urban areas, policing responsibilities are contracted to the federal Royal Canadian Mounted Police.^[113]

Foreign relations and military[link]

Prime Minister Stephen Harper meeting President of the United States Barack Obama in 2009

Canada currently employs a professional, volunteer military force of over 67,000 regular personnel and approximately 43,000 reserve personnel, including supplementary reserves.^[114] The unified Canadian Forces (CF) comprise the Canadian Army, Royal Canadian Navy, and Royal Canadian Air Force. In 2011, Canada's military expenditure totalled approximately C$24.5 billion.^[115]

Canada and the United States share the world's longest undefended border, co-operate on military campaigns and exercises, and are each other's largest trading partner.^[116] Canada nevertheless has an independent foreign policy, most notably maintaining full relations with Cuba and declining to officially participate in the 2003 invasion of Iraq. Canada also maintains historic ties to the United Kingdom and France and to other former British and French colonies through Canada's membership in the Commonwealth of Nations and the Francophonie.^[117] Canada is noted for having a positive relationship with the Netherlands, owing, in part, to its contribution to the Dutch liberation during World War II.^[56]

Canada's strong attachment to the British Empire and Commonwealth led to major participation in British military efforts in the Second Boer War, World War I and World War II. Since then, Canada has been an advocate for multilateralism, making efforts to resolve global issues in collaboration with other nations.^[118][119] Canada was a founding member of the United Nations in 1945 and of NATO in 1949. During the Cold War, Canada was a major contributor to UN forces in the Korean War and founded the North American Aerospace Defense Command (NORAD) in cooperation with the United States to defend against potential aerial attacks from the Soviet Union.^[120]

Canadian Army soldiers from the Royal 22nd Regiment deploying during UNITAS exercises in April 2009

During the Suez Crisis of 1956, future Prime Minister Lester B. Pearson eased tensions by proposing the inception of the United Nations Peacekeeping Force, for which he was awarded the 1957 Nobel Peace Prize.^[121] As this was the first UN peacekeeping mission, Pearson is often credited as the inventor of the concept. Canada has since served in 50 peacekeeping missions, including every UN peacekeeping effort until 1989,^[53] and has since maintained forces in international missions in Rwanda, the former Yugoslavia, and elsewhere; Canada has sometimes faced controversy over its involvement in foreign countries, notably in the 1993 Somalia Affair.^[122]

Canada joined the Organization of American States (OAS) in 1990 and hosted the OAS General Assembly in Windsor, Ontario, in June 2000 and the third Summit of the Americas in Quebec City in April 2001.^[123] Canada seeks to expand its ties to Pacific Rim economies through membership in the Asia-Pacific Economic Cooperation forum (APEC).^[124]

The Halifax-class frigate HMCS Regina, a warship of the Royal Canadian Navy, during the 2004 RIMPAC exercises

In 2001, Canada deployed troops to Afghanistan as part of the US stabilization force and the UN-authorized, NATO-led International Security Assistance Force. Starting in July 2011, Canada began withdrawing its troops from Afghanistan. In all, Canada lost 158 soldiers, one diplomat, two aid workers, and one journalist during the mission,^[125] which cost approximately C$11.3 billion.^[126]

In February 2007, Canada, Italy, the United Kingdom, Norway, and Russia announced their joint commitment to a $1.5-billion project to help develop vaccines for developing nations, and called on other countries to join them.^[127] In August 2007, Canada's territorial claims in the Arctic were challenged after a Russian underwater expedition to the North Pole; Canada has considered that area to be sovereign territory since 1925.^[128] In July 2010, the federal government announced the largest purchase in Canadian military history – the acquisition of 65 F-35 Lightning II jet fighters, totalling C$9 billion.^[129] Between March and October 2011, Canadian forces participated in a UN-mandated NATO intervention into the 2011 Libyan civil war.^[130]

Provinces and territories[link]

Canada is a federation composed of ten provinces and three territories. In turn, these may be grouped into four main regions: Western Canada, Central Canada, Atlantic Canada, and Northern Canada ("Eastern Canada" refers to Central Canada and Atlantic Canada together). Provinces have more autonomy than territories, having responsibility for social programs such as health care, education, and welfare. Together, the provinces collect more revenue than the federal government, an almost unique structure among federations in the world. Using its spending powers, the federal government can initiate national policies in provincial areas, such as the Canada Health Act; the provinces can opt out of these, but rarely do so in practice. Equalization payments are made by the federal government to ensure that reasonably uniform standards of services and taxation are kept between the richer and poorer provinces.^[131]

Economy[link]

Representatives of the governments of Canada, Mexico, and the United States sign the North American Free Trade Agreement (NAFTA) in 1992.

Canada is the world's eleventh-largest economy, with a 2011 nominal GDP of approximately US$1.74 trillion.^[7] It is a member of the Organisation for Economic Co-operation and Development (OECD) and the G8, and is one of the world's top ten trading nations, with a highly globalized economy.^[132][133] Canada is a mixed economy, ranking above the US and most western European nations on the Heritage Foundation's index of economic freedom.^[134] The largest foreign importers of Canadian goods are the United States, the United Kingdom, and Japan.^[135]

In the past century, the growth of Canada's manufacturing, mining, and service sectors has transformed the nation from a largely rural economy to an advanced, urbanized, industrial one. Like many other First World nations, the Canadian economy is dominated by the service industry, which employs about three-quarters of the country's workforce.^[136] However, Canada is unusual among developed countries in the importance of its primary sector, in which the logging and petroleum industries are two of the most prominent elements.^[137]

Canada is one of the few developed nations that are net exporters of energy.^[138] Atlantic Canada possesses vast offshore deposits of natural gas, and Alberta also hosts large oil and gas resources. The immense Athabasca oil sands give Canada the world's second-largest proven oil reserves, after Saudi Arabia.^[139] Canada is additionally one of the world's largest suppliers of agricultural products; the Canadian Prairies are one of the most important global producers of wheat, canola, and other grains.^[140] Canada is a major producer of zinc and uranium, and is a leading exporter of many other minerals, such as gold, nickel, aluminum, and lead.^[141][138] Many towns in northern Canada, where agriculture is difficult, are sustainable because of nearby mines or sources of timber. Canada also has a sizable manufacturing sector centred in southern Ontario and Quebec, with automobiles and aeronautics representing particularly important industries.^[142]

Canada's economic integration with the United States has increased significantly since World War II. The Automotive Products Trade Agreement of 1965 opened Canada's borders to trade in the automobile manufacturing industry. In the 1970s, concerns over energy self-sufficiency and foreign ownership in the manufacturing sectors prompted Prime Minister Pierre Trudeau's Liberal government to enact the National Energy Program (NEP) and the Foreign Investment Review Agency (FIRA).^[143] In the 1980s, Prime Minister Brian Mulroney's Progressive Conservatives abolished the NEP and changed the name of FIRA to "Investment Canada", in order to encourage foreign investment.^[144] The Canada – United States Free Trade Agreement (FTA) of 1988 eliminated tariffs between the two countries, while the North American Free Trade Agreement (NAFTA) expanded the free-trade zone to include Mexico in 1994.^[140] In the mid-1990s, Jean Chrétien's Liberal government began to post annual budgetary surpluses, and steadily paid down the national debt.^[145]

In 2008, Canada's imported goods were worth over $442.9 billion, of which $280.8 billion originated from the United States, $11.7 billion from Japan, and $11.3 billion from the United Kingdom.^[135] The country’s 2009 trade deficit totaled C$4.8 billion, compared with a C$46.9 billion surplus in 2008.^[146]

The global financial crisis of 2008 caused a major recession, which led to a significant rise in unemployment in Canada.^[147] By October 2009, Canada's national unemployment rate reached 8.6 percent, with provincial unemployment rates varying from a low of 5.8 percent in Manitoba to a high of 17 percent in Newfoundland and Labrador.^[148] Between October 2008 and October 2010, the Canadian labour market lost 162,000 full-time jobs and a total of 224,000 permanent jobs.^[149] Canada's federal debt was estimated to total $566.7 billion for the fiscal year 2010–11, up from $463.7 billion in 2008–09.^[150] Canada’s net foreign debt rose by $41 billion to $194 billion in the first quarter of 2010.^[151]

Science and technology[link]

The Canadarm robotic manipulator in action on Space Shuttle Discovery during the STS-116 mission in 2006.

In 2011, Canada spent approximately C$29.9 billion on domestic research and development.^[152] The country has produced ten Nobel laureates in physics, chemistry and medicine,^[153] and is home to a number of global technology firms, such as smartphone maker Research In Motion and video games developer BioWare.^[154] Canada ranks twelfth in the world for Internet users as a proportion of the population, with over 28 million users – equivalent to around 84 percent of its total 2011 population.^[155]

The Canadian Space Agency operates a highly active space program, conducting space, planetary, and aviation research, and developing rockets and satellites. In 1984, Marc Garneau became Canada's first astronaut, serving as payload specialist on NASA's STS-41-G Space Shuttle mission. As of 2012, nine Canadians have flown into space, over the course of fifteen manned missions.^[156]

Canada is a participant in the International Space Station (ISS), and is a pioneer in space robotics, having constructed the Canadarm, Canadarm2 and Dextre robotic manipulators for the ISS and NASA. Since the 1960s, Canada's aerospace industry has designed and built numerous marques of satellite, including Radarsat-1 and 2, ISIS and MOST.^[157] Canada has also produced a successful and widely used sounding rocket, the Black Brant; over 1,000 Black Brants have been launched since the rocket's introduction in 1961.^[158]

Demographics[link]

The 2011 Canadian census counted a total population of 33,476,688, an increase of around 5.9 percent over the 2006 figure.^[6][160] Between 1990 and 2008, the population increased by 5.6 million, equivalent to 20.4 percent overall growth. The main drivers of population growth are immigration and, to a lesser extent, natural growth. About four-fifths of the population lives within 150 kilometres (93 mi) of the United States border.^[161] Approximately 80 percent of Canadians live in urban areas concentrated in the Quebec City – Windsor Corridor, the BC Lower Mainland, and the Calgary–Edmonton Corridor in Alberta.^[162] In common with many other developed countries, Canada is experiencing a demographic shift towards an older population, with more retirees and fewer people of working age. In 2006, the average age was 39.5 years;^[163] by 2011, it had risen to approximately 39.9 years.^[164]

According to the 2006 census, the country's largest self-reported ethnic origin is Canadian (accounting for 32% of the population), followed by English (21%), French (15.8%), Scottish (15.1%), Irish (13.9%), German (10.2%), Italian (4.6%), Chinese (4.3%), First Nations (4.0%), Ukrainian (3.9%), and Dutch (3.3%).^[165] There are 600 recognized First Nations governments or bands, encompassing a total of 1,172,790 people.^[166]

Canada's aboriginal population is growing at almost twice the national rate, and four percent of Canada's population claimed aboriginal identity in 2006. Another 16.2 percent of the population belonged to a non-aboriginal visible minority.^[167] The largest visible minority groups are South Asian (4.0%), Chinese (3.9%) and Black (2.5%). Between 2001 and 2006, the visible minority population rose by 27.2 percent.^[168] In 1961, less than two percent of Canada's population (about 300,000 people) could be classified as belonging to a visible minority group, and less than one percent as aboriginal.^[169] By 2007, almost one in five (19.8%) were foreign-born, with nearly 60 percent of new immigrants coming from Asia (including the Middle East).^[170] The leading sources of immigrants to Canada were China, the Philippines and India.^[171] According to Statistics Canada, visible minority groups could account for a third of the Canadian population by 2031.^[172]

Canada has one of the highest per-capita immigration rates in the world,^[173] driven by economic policy and family reunification, and is aiming for between 240,000 and 265,000 new permanent residents in 2012,^[174] a similar number of immigrants as in recent years.^[175] In 2010, a record 280,636 people immigrated to Canada.^[176] New immigrants settle mostly in major urban areas like Toronto and Vancouver.^[177] Canada also accepts large numbers of refugees.^[178] The country resettles over one in 10 of the world’s refugees.^[179]

According to the 2001 census, 77.1 percent of Canadians identify as Christian; of this, Catholics make up the largest group, accounting for 43.6 percent of the population. The largest Protestant denomination is the United Church of Canada (accounting for 9.5% of Canadians), followed by Anglicans (6.8%), Baptists (2.4%), Lutherans (2%), and other Christian denominations (4.4%). About 16.5 percent declare no religious affiliation, and the remaining 6.3 percent are affiliated with non-Christian religions, the largest of which are Islam (2.0%) and Judaism (1.1%).^[180]

Canadian provinces and territories are responsible for education. The mandatory school age ranges between 5–7 to 16–18 years,^[181] contributing to an adult literacy rate of 99 percent.^[77] In 2002, 43 percent of Canadians aged 25 to 64 possessed a post-secondary education; for those aged 25 to 34, the rate of post-secondary education reached 51 percent.^[182] The Programme for International Student Assessment indicates that Canadian students rank well above the OECD average, particularly in mathematics, sciences, and reading.^[183]

Language[link]

In 2006, about 17.4 percent of the population were reportedly bilingual, being able to conduct a conversation in both official languages.

  English – 57.8%

  English and French (Bilingual) – 17.4%

  French – 22.1%

  Sparsely populated area (<0.4 persons per km²)

Canada's two official languages are Canadian English and Canadian French. Official bilingualism is defined in the Canadian Charter of Rights and Freedoms, the Official Languages Act, and Official Language Regulations; it is applied by the Commissioner of Official Languages. English and French have equal status in federal courts, Parliament, and in all federal institutions. Citizens have the right, where there is sufficient demand, to receive federal government services in either English or French, and official-language minorities are guaranteed their own schools in all provinces and territories.^[184]

English and French are the first languages of 59.7 and 23.2 percent of the population respectively. Approximately 98 percent of Canadians speak English or French: 57.8 percent speak English only, 22.1 percent speak French only, and 17.4 percent speak both.^[185] The English and French official-language communities, defined by the first official language spoken, constitute 73.0 and 23.6 percent of the population respectively.^[186]

The 1977 Charter of the French Language established French as the official language of Quebec.^[187] Although more than 85 percent of French-speaking Canadians live in Quebec, there are substantial Francophone populations in Ontario, Alberta, and southern Manitoba; Ontario has the largest French-speaking population outside Quebec.^[188] New Brunswick, the only officially bilingual province, has a French-speaking Acadian minority constituting 33 percent of the population. There are also clusters of Acadians in southwestern Nova Scotia, on Cape Breton Island, and through central and western Prince Edward Island.^[189]

Other provinces have no official languages as such, but French is used as a language of instruction, in courts, and for other government services, in addition to English. Manitoba, Ontario, and Quebec allow for both English and French to be spoken in the provincial legislatures, and laws are enacted in both languages. In Ontario, French has some legal status, but is not fully co-official.^[190] There are 11 Aboriginal language groups, composed of more than 65 distinct dialects.^[191] Of these, only the Cree, Inuktitut and Ojibway languages have a large enough population of fluent speakers to be considered viable to survive in the long term.^[192] Several aboriginal languages have official status in the Northwest Territories.^[193] Inuktitut is the majority language in Nunavut, and is one of three official languages in the territory.^[194]

In 2005, over six million people in Canada listed a non-official language as their mother tongue. Some of the most common non-official first languages include Chinese (mainly Cantonese; 1,012,065 first-language speakers), Italian (455,040), German (450,570), Punjabi (367,505) and Spanish (345,345).^[195] English and French are the most-spoken home languages, being spoken at home by 68.3 and 22.3 percent of the population respectively.^[196]

Culture[link]

Bill Reid's 1980 sculpture Raven and The First Men. The Raven is a figure common to many of Canada's Aboriginal mythologies.

Canadian society is often depicted as being "diverse and multicultural".^[197][198] Canada's culture draws influences from its broad range of constituent nationalities, and policies that promote multiculturalism are constitutionally protected.^[199] In Quebec, cultural identity is strong, and many French-speaking commentators speak of a culture of Quebec that is distinct from English Canadian culture.^[200] However, as a whole, Canada is in theory a cultural mosaic – a collection of several regional, aboriginal, and ethnic subcultures.^[201] Government policies such as publicly funded health care, higher taxation to redistribute wealth, the outlawing of capital punishment, strong efforts to eliminate poverty, an emphasis on multiculturalism, strict gun control, and the legalization of same-sex marriage are further social indicators of Canada's political and cultural values.^[202]