By: Stephanie Molloy, Canadian physiotherapist
Within Canada, physiotherapy services are offered by both the public and private sectors.
Public settings primarily include patients within the hospital, outpatient clinics within hospitals, rehabilitation centers, and receiving care at home. The most important detail here is that public services are free to the patient. However, the services are limited and difficult to access - requiring a provincial health care card and a medical referral.
Contrary to public, private practices accept all patients - no referral needed! This is ideal for people who are experiencing chronic or new pain, or suspect they have an injury. These services are not covered by Canada’s “free healthcare” and are paid out of pocket by the patient, or by private insurance if that is something they have.
It seems that between these two sectors, there’s absolutely a way for everybody to be seen and treated - fantastic! Except… That is not the case.
A study done in Quebec found that the median wait time for outpatient public physiotherapy was more than six months (1). Wait times for physiotherapy are an ongoing issue across Canada, with patients stating concerns of losing their mobility without the opportunity to see a physiotherapist (2). If you’re tired of waiting or worried that you need to get seen as soon as possible you can choose to go see a private physiotherapist. This visit on average will cost you between $95-125 per hour, and usually even more for your initial evaluation (3). Let’s not forget that physiotherapy is rarely a single session, it can range from needing 2-3 sessions to lasting multiple weeks. Over the course of treatment, you can easily spend $1,000, and it can often be even more. Some people have insurance plans that cover these costs - either entirely or partially, but there are many people without any form of insurance coverage. In 2022 it was estimated that 200,000 to 500,000 Canadians are living without health insurance (4). Within those with insurance, some only have partial coverage for physiotherapy, while others have none at all.
This goes to show that, for the general population, public physiotherapy is functionally non-existent, and private physiotherapy is cost prohibitive. For many individuals this means that physiotherapy is inaccessible… and therein lies the problem. The lack of accessibility to physiotherapy in Canada is inherently unethical, unjust, and, arguably, a human rights violation.
The Right To Access Care
I am going to highlight four important documents, all of which involve Canada and/or its peoples, and which discuss people's right to care.
The Declaration of Montreal
During the First International Pain Summit on September 3, 2010, the Declaration of Montreal was created (5). This document states that access to pain management is a fundamental human right.
Among other things, they specifically noted the following obligation:
1. The obligation of governments and all health care institutions, within the scope of
the legal limits of their authority and taking into account the health care resources
reasonably available, to establish laws, policies, and systems that will help to
promote, and will certainly not inhibit, the access of people in pain to fully
adequate pain management. Failure to establish such laws, policies, and systems is
unethical and a breach of the human rights of people harmed as a result.
Notably, the declaration is endorsed by the Pain Science Division of the Canadian Physiotherapy Association.
As physiotherapy services are incredibly inaccessible (primarily through their prohibitive cost or massive waitlists), and are very beneficial for pain management and treatment, it is clear that Canada is not fulfilling their obligations of ensuring adequate pain management to those experiencing pain.
The Universal Declaration of Human Rights
The Universal Declaration of Human Rights also clearly protects the right to appropriate healthcare. This declaration was drafted in 1948 by The United Nations, of which Canada is a part (6). I would like to bring your attention to two specific articles:
Article 21
2. Everyone has the right to equal access to public service in his country.
Article 25
1. Everyone has the right to a standard of living adequate for the health and well
being of himself and of his family, including food, clothing, housing and medical care
and necessary social services, and the right to security in the event of
unemployment, sickness, disability, widowhood, old age or other lack of livelihood in
circumstances beyond his control.
One would hope that in a first world country with universal healthcare, everyone would have equal access to this public service. Alas, that is not the case. In order to access health services, one must have a provincial health care card - which can only be obtained by having an address to put on your application and receive your health card through the mail. For homeless individuals without a permanent or safe address, it is extremely difficult (if not impossible) to receive a card and therefore functionally impossible to access health services such as public physiotherapy.
In regards to Article 25, this human right is simply not being met through the general inaccessible nature of physiotherapy services. Physiotherapy is a necessary medical service in regards to health, well-being, sickness, and disability.
The United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP)
In 2007 the United Nations’ General Assembly adopted the United Nations Declaration on the Rights of Indigenous Peoples in 2007. This document was created to create a “a universal framework of minimum standards for the survival, dignity and well-being of the indigenous peoples of the world” (7)
Canada currently officially supports this declaration, despite originally voting against it.
Three articles of this declaration are of note:
Article 7
1. Indigenous individuals have the rights to life, physical and mental integrity, liberty
and security of a person.
Article 21
1. Indigenous peoples have the right, without discrimination, to the improvement
of their economic and social conditions, including, inter alia, in the areas of education,
employment, vocational training and retraining, housing, sanitation, health and social
security.
2. States shall take effective measures and, where appropriate, special measures to
ensure continuing improvement of their economic and social conditions. Particular
attention shall be paid to the rights and special needs of indigenous elders, women,
youth, children and persons with disabilities.
Article 24
2. Indigenous individuals have an equal right to the enjoyment of the highest
attainable standard of physical and mental health. States shall take the necessary
steps with a view to achieving progressively the full realization of this right.
In Canada, 44-62% of Indigenous peoples have one or more chronic health conditions. The most common of these include diabetes, arthritis, and back pain (8), which are all conditions that can be treated and managed with physiotherapy services. Additionally, the rate of disability in Indigenous peoples in Canada is two to three times that of the general population (9). Even though the healthcare needs of Indigenous peoples are much greater than the general population physiotherapy services are even harder for them to access. This can be seen through the fact that physiotherapy services are incredibly limited on all Indigenous reserves and rural communities (8), and through the disproportionate rates of homelessness experienced by Indigenous peoples (23 times that of general population - 10), which creates a unique set of barriers toward physiotherapy services. Although there have been some efforts by the government to reduce homelessness in Indigenous peoples (see Quebec - 11), there is little emphasis on healthcare or physiotherapy services - leaving these Indigenous Rights unfulfilled.
The Truth and Reconciliation Commission of Canada: Calls to Action
In 2005 the Indian Residential Schools class-action lawsuit came to a settlement. This lawsuit was founded on the understanding that “Canada and certain religious organizations operated Indian Residential Schools for the education of aboriginal children and certain harms and abuses were committed against those children” (12), and that reparation and reconciliation were long overdue. One of the elements of this settlement was the “establishment of the Truth and Reconciliation Commission of Canada to facilitate reconciliation among former students, their families, their communities and all Canadians” (13). The TRC report took 6 years and resulted in 94 calls to action, one of which I would specifically like to highlight:
19. We call upon the federal government, in consultation with Aboriginal peoples, to
establish measurable goals to identify and close the gaps in health outcomes
between Aboriginal and non-Aboriginal communities, and to publish annual
progress reports and assess long term trends. Such efforts would focus on indicators
such as: infant mortality, maternal health, suicide, mental health, addictions, life
expectancy, birth rates, infant and child health issues, chronic diseases, illness and
injury incidence, and the availability of appropriate health services.
Similarly to UNDRIP above, many of the conditions outlined needing improvement in the TRC report can be treated and prevented by physiotherapy services. As long as these services remain inaccessible, Canada is not fulfilling these calls to actions that they themselves commissioned.
Case Study: Canada’s Homeless Population
Canada’s homeless population provides the perfect example of Canada failing to uphold the rights owed to its citizens through its lack of provision of accessible physiotherapy services.
Homeless individuals in Canada suffer from health conditions at a much higher rate than the general population. For example, estimates show that 45% of people experiencing homelessness are disabled or diagnosed with a mental illness, which is more than 3 times higher than the general population (14). Of people experiencing homelessness in Canada 50% had a serious health condition, with 63% having more than one (14). In regards to traumatic brain injury, the prevalence of general Canadians living with TBI is 2% (15), whereas almost 50% of homeless Canadians have had a brain injury (16).
Undoubtedly this population has extreme healthcare needs, many of which are once again treatable and/or preventable by physiotherapy services. Additionally, the lack of accessibility to these services is exacerbated within the population.
This population often has no address with which to register for a provincial health care card, no access to a general practitioner for a referral, no health insurance to help cover the expensive costs, no home or safe space in which to receive domiciliary care, no phone or email access to be contacted for follow up appointments, difficulty accessing transportation to get to appointments, and many more compounding variables which make physiotherapy nearly impossible to access.
Furthermore, Canada has not stepped up to fill this massive gap in health services. From my own research the only evidence I could find of physiotherapy services specifically dedicated to homeless individuals was a (successful) pilot project in Saskatchewan in 2019, which has not been followed up (17). Some services do exist that offer physiotherapy at a reduced rate or for free for individuals without health insurance. These are all university affiliated clinics which depend on free student labor during their clinical placements, and research has not been specifically if these clinics are able to reach the homeless population itself (18).
Is Public Physiotherapy Possible?
Case Study: Belgium vs. Canada
Belgium and Canada are both developed, affluent countries, and therefore make a good comparison. In Belgium, physiotherapy services are widely available and completely covered. Individuals do not need a referral and can make an appointment whenever they would like, for whatever problem they deem needing treatment. Additionally, there are no long waiting times to be seen (19). Patients can be seen through two routes: physiotherapy specifically, or Physical and Rehabilitation Medicine clinics - which also offer physiotherapy.
Belgium spends approximately $398 CAD a year per patient on physiotherapy services (19), although this may seem like a large investment, overall trends suggest otherwise. In overall public healthcare, in 2020 Belgium spent $4,536 CAD per person a year (20). In comparison, Canada’s total health expenditure (in 2019) was $7,064 CAD per Canadian (21). One may think that having all physiotherapy services public would cost more taxpayer dollars, but as we can see in Belgium this is not the case - their overall healthcare spending is less. Is it possible that physiotherapy and preventing serious conditions could actually decrease healthcare costs and usage?
To look even more closely at this relationship we can compare hip fractures across the two countries. In 2018, pelvic and acetabular fractures in Belgium had an incidence of 37.6 per 100,000 (22) In Canada in 2016, the incidence of hip fracture was 147 per 100,000 people (23) - that’s 4x higher the rate than Belgium. Additionally, in Canada acute care alone for hip fractures costs $619,315,477 (24), not including all the rehabilitation care necessary.
But does this prove anything? Is physiotherapy really the cause of Belgium having almost 110 less fractures per 100,000 than Canada? Although we cannot objectively say it is 100% because of physiotherapy, it’s role cannot go unnoticed. Falling is the leading cause of fractures making up more than 95% of the reason for injury, a problem which is worsened when someone has osteoporosis (25). Physiotherapy has been shown to aid in the prevention of both these primary causes, as seen by Bennell et al. (2000) (26), and Sherrington & Tiedemann (2015) (27).
So not only is free, publicly covered physiotherapy with no wait times possible - it is in fact the cheaper alternative.
Conclusion
Across Canada, the provision of physiotherapy services is not accessible for many Canadian and Indigenous peoples. Not only is the lack of services directly costing all Canadians through elevated healthcare costs nationally, but it is a breach of our human rights. Every single individual has the right to pain management and appropriate care for their health needs, but in Canada this right is inaccessible.
Knowing that everybody deserves timely access to care; knowing that physiotherapy can help an incredibly wide range of the issues people face; knowing that physiotherapy is inaccessible in Canada; and knowing that it is possible to provide better, accessible services - makes it impossible to ignore this issue anymore.
Canada, we have to do better. It is unethical to do anything less, to provide anything less than accessible care, to sit in the comfort of “but physiotherapy has always been delivered this way here”.
As a physiotherapist I have pledged to do no harm, and that means advocating for the accessibility of my professional services. Sitting back and doing nothing in the face of such injustice would break this pledge. I call on Canada and all its provinces and territories to do better and provide every Canadian and Indigenous person here with the agency and ability to access safe and accessible physiotherapy services in a timely manner.
It is possible to do better. So let's do it.
Photo references:
1. Photo by Andre Furtado: https://www.pexels.com/photo/low-angle-photography-of-high-rise-building-370717/
2. Photo by Brett Sayles: https://www.pexels.com/photo/blue-tent-and-shopping-trolley-on-street-6916080/
3. Photo by Paul Deetman: https://www.pexels.com/photo/photo-of-parc-du-cinquantenaire-2960887/
References:
Access to publicly funded outpatient physiotherapy services in Quebec: waiting lists and management strategies (2016) https://www.tandfonline.com/doi/abs/10.1080/09638288.2016.1238967
Long waits for publicly funded physiotherapists 'disgraceful,' says senior (2019) https://www.cbc.ca/news/canada/nova-scotia/physiotherapists-long-wait-times-nova-scotia-1.5214864
How Much Does Physiotherapy Cost in Canada? (2021) https://groupenroll.ca/how-much-does-physiotherapy-cost-in-canada/
Pay-as-you-go health care: Uninsured people in Canada face sky-high bills, delays in treatment, doctors say (2020) https://www.cbc.ca/radio/whitecoat/pay-as-you-go-health-care-uninsured-people-in-canada-face-sky-high-bills-delays-in-treatment-doctors-say-1.5426679
Access to Pain Management: Declaration of Montreal (2010) https://www.iasp-pain.org/advocacy/iasp-statements/access-to-pain-management-declaration-of-montreal/
Universal Declaration of Human Rights (1948) https://www.un.org/en/about-us/universal-declaration-of-human-rights
United Nations Declaration on the Rights of Indigenous Peoples (2007) https://www.un.org/development/desa/indigenouspeoples/declaration-on-the-rights-of-indigenous-peoples.html
Access to Physiotherapy for Aboriginal Peoples in Canada (2014) https://saskphysio.org/images/stories/pdfs/Announcements_2014/Access_to_Physiotherapy_for_Aboriginal_Peoples_in_Canada_April_2014_FINAL.pdf
Physiotherapy and Indigenous Health: Are we there yet? (2020) https://mbphysio.org/physiotherapyandindigenoushealtharticledecember162020.pdf
Housing and Homelessness Sector: First Nations Homelessness Action Plan (2021) https://www.afn.ca/wp-content/uploads/2021/12/2.-21-10-18-Exec-Summary-of-Homelessness-Research-EN.pdf
Quebec announces $280-million plan to improve services for homeless population (2021) https://montreal.ctvnews.ca/quebec-announces-280-million-plan-to-improve-services-for-homeless-population-1.5627391
Indian Residential Schools Settlement Agreement (2008) https://www.residentialschoolsettlement.ca/IRS%20Settlement%20Agreement-%20ENGLISH.pdf
Truth and Reconciliation Commission of Canada https://www.rcaanc-cirnac.gc.ca/eng/1450124405592/1529106060525
People with Disabilities, Canadian Observatory on Homelessness https://www.homelesshub.ca/about-homelessness/population-specific/people-disabilities
Statistics on brain injury, Brain Injury Canada https://braininjurycanada.ca/en/statistics/#:~:text=In%20Canada%2C%202%25%20of%20the,and%20accidents%20being%20major%20causes.
Homelessness, Brain Injury Canada https://braininjurycanada.ca/en/homelessness/#:~:text=Approximately%2050%25%20of%20people%20experiencing,symptoms%20and%20outcomes%5B3%5D.
Enhancing Access to Physical Therapy Services for People Experiencing Poverty and Homelessness: The Lighthouse Pilot Project (2019) https://www.utpjournals.press/doi/abs/10.3138/ptc.2017-85.pc?journalCode=ptc
Examples of university student-led physiotherapy clinics that offer free or reduced rates can be found at Queens University, McMaster University, University of Toronto, and the University of British Columbia.
Consumption of physiotherapy and physical and rehabilitation medicine in Belgium (2008) https://kce.fgov.be/sites/default/files/2021-11/d20081027356.pdf
Total healthcare expenditure per capita in Belgium in 2020, by financing type (2022) https://www.statista.com/statistics/1324523/health-spending-per-capita-belgium-by-type/#:~:text=In%202020%2C%20public%20per%20capita,Belgium%20reached%20over%204%2C272%20euros.
National Health Expenditure Trends 2020 (2020) https://www.cihi.ca/sites/default/files/document/nhex-trends-2020-narrative-report-en.pdf
Epidemiology and secular trends of pelvic fractures in Belgium: A retrospective, population-based, nationwide observational study (2021) https://pubmed.ncbi.nlm.nih.gov/34365026/
Osteoporosis and related fractures in Canada: Report from the Canadian Chronic Disease Surveillance System 2020 (2020) https://www.canada.ca/en/public-health/services/publications/diseases-conditions/osteoporosis-related-fractures-2020.html
Fracture incidence and costs by province (2013) https://fls.osteoporosis.ca/wp-content/uploads/FLS-TOOLKIT-App-B.pdf
Hip Fractures Among Older Adults https://www.cdc.gov/falls/hip-fractures.html#:~:text=More%20than%2095%25%20of%20hip,2%20usually%20by%20falling%20sideways.&text=Women%20experience%20three%2Dquarters%20of%20all%20hip%20fractures.&text=Women%20fall%20more%20often%20than,them%20more%20likely%20to%20break.
The role of physiotherapy in the prevention and treatment of osteoporosis (2000) https://www.sciencedirect.com/science/article/pii/S1356689X00903692?casa_token=nNnCEguHDlsAAAAA:KCJNPVIC4XT-_gRPcj6cNnLnOpJBl45sbTau8nH2Jt7DiTIKpioK70Hh9WKqiZiq6VH_ujyY
Physiotherapy in the prevention of falls in older people (2015) https://www.sciencedirect.com/science/article/pii/S1836955315000120