Basket Of Services Research Articles

Patients Experience Improvements in Pain and Quality of Life When Treated at a Physician Led Integrative Medicine Clinic at a Large Air Force Military Treatment Facility

ObjectiveA large percentage of military treatment facilities (MTFs) offer at least one type of complementary medicine and 80% of patients surveyed felt that integrative therapies should be routinely offered at all MTFs. We are the first to offer the breadth of modalities outlined below in a dedicated MTF Integrative Medicine Clinic (IMC). The purpose of this study was to determine whether the basket of services offered at our IMC improved patient pain and quality of life. Design and SettingPatient outcomes over a three-year period were retrospectively evaluated from a single cohort. Patients referred to the IMC for chronic pain at the MTF recorded pain scores using the Defense and Veterans Pain Rating Scale (DVPRS) and completed the Dallas Pain Questionnaire (DPQ), a 16-item visual analog quality of life questionnaire, at each visit. They also completed a non-validated quality of life question on discharge from the clinic. Modalities used include microcurrent therapies, extracorporeal shockwave therapy, medical Acupuncture, myofascial release techniques, low-level laser therapy, and the AllCore360. Results761 patients were seen from August 2019 to October 2022 in over 3,280 clinic visits. On average per visit, DVPRS scores were reduced from 4.4 to 1.5 (MD 2.9; 95%CI, 2.7-3.1). Total DPQ scores were reduced by 16.5% (MD 27.7; 95%CI 22.7-32.7). On discharge from the clinic 81% of patients reported their quality of life was either “a lot better” or “somewhat better.” ConclusionsIf implemented, we believe comparable clinics across the Department of Defense can replicate these improvements in patient-oriented outcomes.

The child dental care reform in Israel – service uptake from 2011 to 2022

BackgroundThe 2010 Child Dental Care Reform of the National Health Insurance Law marked a turning point in the Israeli oral healthcare system by establishing Universal Health Coverage of dental care for children. Initially, the reform included children up to age 8 and gradually expanded to age 18 in 2019. The basket of services includes preventive and restorative treatments provided by the four Health Maintenance Organizations (HMO). The aim of this study was to examine the uptake of child dental services during the first decade of the reform.MethodsA retrospective analysis was conducted to determine the treatment uptake, type and amount of the services delivered based on annual service utilization reports submitted by the HMOs to the Ministry of Health in the years 2011–2022.ResultsThe number of insured children increased from 1,546,857 in 2011 to 3,178,238 in 2022. The uptake of dental services gradually increased during the study period with a slight decrease in 2020. The percentage of children who used the services gradually increased from 8 to 33%, with the incremental inclusion of additional age groups. From 2012 onwards the most common treatments provided were preventive, however the single most common treatment was dental restoration. In 2022 35% of the population of Israel was under the age of 18. Out of these, about a third received dental treatment via the HMOs. This is a significant achievement, since before the reform all treatments were paid out-of-pocket. After a short period of increasing uptake, a stable service utilization pattern was evident that can indicate better public awareness and service acceptance.ConclusionAlthough this is a reasonable uptake, additional efforts are required to increase the number of children receiving dental care within the public insurance. Such an effort can be part of a multi-disciplinary approach, in which pediatricians and public health nurses can play a vital role in dental caries prevention, enhancement of awareness and service utilization.

Uptake of dental hygienist services by the Israeli 65+ age group.

To learn about the use patterns of dental hygienist services, by the 65+ age group in Israel and to identify the main barriers facing different population groups. Telephone interviews with a representative sample of 512 older adults aged 65 and over were conducted from February to April 2020. About 50% of the older adults aged 65 and over visited a dentist (2.9 visits on average) and 35% visited a dental hygienist in the year preceding the interviews. 17% reported never visiting a dentist and 45% never received care from a dental hygienist. Dental care use rates are lower in the outlying areas of the country, among non-Jews and among those who find it difficult to cover monthly household expenses. Those who regularly visit a dental hygienist maintain a preventive oral health routine, including tooth brushing and visits to the dentist for periodic preventive check-ups. They are aware of the harmful effects of eating sweets in between meals. Most of the older adults aged 65 and over are unaware of the reform under which hygienist' care was included in the basket of services provided by health plans. There is underutilization of dental hygienist services and lack of awareness of proper oral health behaviour in the lower socioeconomic group. As less than 50% of older adults are aware of the legal rights for dental care, there is a need to raise awareness of the reform and the services provided under it.

Unfolding the link between multiple ecosystem services and bundles of functional traits to design multifunctional crop variety mixtures

In face of the current environmental challenges, developing multifunctional cropping systems is increasingly needed, and crop variety mixtures are particularly interesting since they can deliver diverse services including grain production, yield stability, N2O production regulation, disease control, and reduction of N-fertilizer losses. However, the relationships between intraspecific diversity and ecosystem multifunctionality are poorly understood so far, and practitioners lack science-based guidance to design mixtures. We used a pool of 16 bread wheat varieties classified into 4 functional groups based on 26 below- and aboveground functional traits, to conduct a field trial (88 large plots cultivated with single varieties or mixtures of 2, 4, or 8 varieties), quantifying 15 provisioning and regulating services for each plot. To assess yield stability between local conditions and years, the trial was replicated at 4 other locations and for 2 years, using 2 managements each time. We analyzed how variety number and functional groups predicted the variance in services, and applied in an innovative manner the RLQ co-inertia analysis to relate the (variety × traits) matrix Q to a (plot × services) matrix R, using a (plot × variety) composition matrix L as a link. Our results show that using variety mixtures allowed delivery of baskets of services not reachable when cultivating single varieties, and that mixtures mitigated tradeoffs between different pairs of services. Variety number or functional groups poorly predicted the variance in services, but the RLQ approach allowed the identification of groups of plots delivering consistent baskets of services. Moreover, we demonstrated for the first-time significant relationships between specific baskets of services and bundles of variety traits. We discuss how our results increase our understanding of intraspecific diversity–agroecosystem multifunctionality relationships, and propose the next steps using our new approach to support practitioners for designing variety mixtures that provide particular baskets of services.

Comparing Changes in Medicare Reimbursement for Radiation Oncology and Medical Oncology (2010-2020)

A recent study found that radiation oncology (RO) has seen significant declines in Medicare reimbursement (MCR) from 2010-2019. While it is presumed that other cancer subspecialties have seen decreasing MCR, to our knowledge, there are no studies directly comparing changes in MCR between RO and other oncology subspecialties. In this study, we analyze changes in MCR from 2010-2020 for both RO and medical oncology. We hypothesized that the declines in MCR will be similar between the two fields. The publicly available Physician/Supplier Procedure Summary (PSPS) database was used for all years from 2010-2020. All reimbursement for providers with primary provider codes 92 (RO) and 83 and 90 (heme/onc and medical oncology, respectively) were analyzed. For the 150 most highly-reimbursed HCPCS codes for each specialty in 2010, the total allowed charge for each code was corrected for inflation and then divided by the number of submitted claims to calculate average MCR per code for each year. For each code and each specialty, the 2020 billing frequency was multiplied by the calculated average reimbursement per claim in a given year to calculate what the reimbursement would have been in that year using 2020 dollars and utilization rates (projected reimbursement). The projected reimbursement was summed for all HCPCS codes in each year for each specialty to calculate an aggregate MCR for that specialty for that year. This aggregate MCR was then compared with the actual 2020 reimbursement for that basket of codes to calculate the change in MCR over time. Both medical and radiation oncology saw decreases in projected vs. actual MCR from 2010-2020 for this basket of services (Table). Adjusting for inflation and utilization, RO MCR declined by $0.7 billion (B) (-29.0%) from 2010 to 2020 and by $0.2B (-10.5%) from 2015 to 2020 while medical oncology MCR declined by $0.8B (-14.7%) from 2010-2020 and by $0.4B (-6.6%) from 2015-2020. The average decrease per year in projected vs. actual reimbursement for RO was 2.9% (2010 to 2015) and 1.05% (2015 to 2020) and for medical oncology was 1.5% (2010-2015) and 0.7% (2015-2020), respectively. Adjusting for inflation, Medicare reimbursement for a large array of services has declined for both medical oncology and RO from 2010 - 2020. Contrary to our hypothesis, RO reported a 97% greater relative decline in reimbursement compared with medical oncology from 2010 - 2020. Significant decreases in reimbursement to both fields and their potential implications on patient care and access to care should be considered by policymakers while shifting towards an episode-based Alternative Payment Model and when considering further cuts to Medicare reimbursement.

Factors affecting the use of dental services among Arab children in Israel: a qualitative study

BackgroundIn 2010, Israel reformed its hitherto dominantly privately financed dental services and included preventative and restorative dental care for children in the publicly-funded basket of healthcare services. A survey conducted by Brookdale Institute, found that only 67% of low-income Israeli-Arab children were using the new service (compared to 85% of Jewish children) while the majority of others continue using privately funded services. The aim of this study is to explore and explain Israeli-Arab children’s low utilization of publicly-funded preventive and restorative dental care.MethodsA qualitative study designed to describe and understand the parents’ motivations and choices. As a preliminary stage, eight semi-structured interviews were conducted with directors of HMO dental departments and Israeli-Arab dentists. In the second stage, ten one-on-one interviews with parents, and five focus group discussions with 55 parents held on February–March 2017. All discussions in the focus groups were conducted in Arabic and each group was moderated by one of the research team accompanied by another person who documented and recorded the discussion. All interviews and discussions were recorded, transcribed in full and translated into Hebrew.ResultsThe prevalent attitude is that one goes to the dentist only when there is a serious problem. The importance of preventive care is not appreciated. A childhood fear of the drill is very remembered and passed onto the children. Social and cultural factors such as kinship with service providers (GPs and dentists) influence the choice and utilization of health services. Economic barriers are still existing since even the small co-payment is daunting to low-income parents of large families. Provision of the public service is inadequate in some Arab villages.ConclusionsThe extension of Israel's National Health Insurance Law’s basket of services to include dental care for children, while important, is not sufficiently embraced by Israeli Arab children. The remaining barriers include poor living conditions, low educational level that requires very clear sharing of information about the new service, and the resistance of cultural and social traditions. Public dental services providers should focus on conveying relevant oral health messages to the parents too, either through their children or directly.

An Examination of Israel’s Model of a Basket of Services for Persons with Psychiatric Disabilities: Its Relevance to India

An Examination of Israel’s Model of a Basket of Services for Persons with Psychiatric Disabilities: Its Relevance to India

Age, morbidity, or something else? A residual approach using microdata to measure the impact of technological progress on health care expenditure.

This study measures the increment of health care expenditure (HCE) that can be attributed to technological progress and change in medical practice by using a residual approach and microdata. We examine repeated cross‐sections of individuals experiencing an initial health shock at different point in time over a 10‐year window and capture the impact of unobservable technology and medical practice to which they are exposed after allowing for differences in health and socioeconomic characteristics. We decompose the residual increment in the part that is due to the effect of delaying time to death, that is, individuals surviving longer after a health shock and thus contributing longer to the demand of care, and the part that is due to increasing intensity of resource use, that is, the basket of services becoming more expensive to allow for the cost of innovation. We use data from the Danish National Health System that offers universal coverage and is free of charge at the point of access. We find that technological progress and change in medical practice can explain about 60% of the increment of HCE, in line with macroeconomic studies that traditionally investigate this subject.

Oral health of the 65+ age group in Israel-2020

BackgroundIn 2019, a reform of dental services for older adults was implemented in Israel to improve access and reduce barriers that stood in their way. The reform stipulated that preventive and restorative dentistry would be included in the basket of services of the National Health Insurance Law. The current study was conducted by the Myers-JDC-Brookdale Institute (MJB) and the Division of Dental Health of Israel’s Ministry of Health to examine the dental status and patterns of utilizations of dental services among the 65+ age group. This paper reports on the dental status of the 65+ age group in comparison with the same population two decades earlier.GoalsTo describe the dental status of Israel’s 65+ age group, and to identify the population at risk of dental morbidity.MethodologyTelephone interviews were conducted with a representative sample of 512 older adults aged 65+, from February to April 2020.Main findingsSome two-thirds of the 65+ age group assessed their oral health as good or very good. Twenty-four percent did not have natural teeth, while the rest had 19 teeth on average. Ten percent had not lost any teeth. In the 65–74 age group, 19% had no natural teeth and the rest had 20 teeth on average. In contrast, in the 85+ age group, 38% were edentulous and the rest had 13 teeth on average. Of the older adults who found it difficult to cover their monthly expenses, 39% were edentulous—twice the percentage of those who did manage to cover their monthly expenses (19%). Of the 65+ age group 44% had dentures—37% in the 65–74 age group, and 66% in the 85+ age group. Approximately 40% of the 65+ age group saw a dentist for preventive check-ups. The rest did not, mainly due to lack of awareness of the importance of doing so.Conclusions and recommendationsThe perceived status of oral health among the 65+ age group is currently better than it was 22 years ago. However, despite the improvement in oral health and health behavior, there are still barriers to the utilization of dental services. The main barriers are a lack of awareness of the importance of proper health behavior, and the cost of care for people with financial difficulty. This study provides decision-makers with data on the status of oral health, the utilization of dental services and the geographical disparities. The findings will help policy makers evaluate the effectiveness of the reform and fine tuning it in the future. Policies should be instated to increase awareness of constituencies and their access to the services, in addition to the entitlements the reform granted.

A realist review of the home care literature and its blind spots.

There is a large body of literature from all over the world that describes, analyzes, or evaluates home care models and interventions. The present article aims to identify the practical lessons that can be gained from a systematic examination of that literature. We conducted a three-step sequential search process from which 113 documents were selected. That corpus was then narratively analysed according to a realist review approach. A first level of observation is that there are multiple blind spots in the existing literature on home care. The definition and delimitation of what constitutes home care services is generally under-discussed. In the same way, the composition of the basket of care provided and its fit with the need of recipients is under-addressed. Finally, the literature relies heavily on RCTs whose practical contribution to decisions or policy is disputable. At a second level, our analysis suggests that three mechanisms (system integration, case management and relational continuity) are core characteristics of home care models' effectiveness. We conclude by providing advice for supporting the design and implementation of stronger home care delivery systems. Our analysis suggests that doing so implies a series of sequential steps: identify what system-level goals the model should achieve and which populations it should serve; identify what type of services are likely to achieve those goals in order to establish a basket of services; and finally, identify the best ways and specific means to effectively and efficiently provide those services. Those same steps can also support ex-post evaluations of existing home care systems.

P2LBS: Privacy Provisioning in Location-Based Services

The acceptability of a location-based service (LBS) hinges on its ability to efficiently provide service while protecting both the privacy of the customer and the server's economic interests. These include the privacy of the user, point-of-interests (POIs) privacy of the service provider, and provision for anonymous payment. Existing schemes fulfill these requirements only partially. Most of the schemes protect the query privacy of the user and the privacy of the services provided by the server, however, at high computation and communication costs. We propose a privacy-provisioning location-based service(P2LBS) scheme that provides unconditional privacy to the user's query and protects the basket of services offered by the service provider from unnecessary revelation along with an inbuilt anonymous payment scheme. To ensure the authentication of the user and the server, the P2LBS scheme uses a ring signature and anonymous payment protocol respectively. Query privacy and the services' reply privacy are provided through an oblivious transfer (OT) protocol. Results show that the P2LBS scheme is efficient compared to other current state-of-the-art schemes in terms of communication and computation costs. It fulfills all the end-to-end requirements needed to make an LBS scheme viable.

Stirring the pot: Switching from blended fee‐for‐service to blended capitation models of physician remuneration

In Canada's most populous province, Ontario, family physicians may choose between the blended fee-for-service (Family Health Group [FHG]) and blended capitation (Family Health Organization [FHO] payment models). Both models incentivize physicians to provide after-hours (AH) and comprehensive care, but FHO physicians receive a capitation payment per enrolled patient adjusted for age and sex, plus a reduced fee-for-service while FHG physicians are paid by fee-for-service. We develop a theoretical model of physician labor supply with multitasking to predict their behavior under FHG and FHO, and estimable equations are derived to test the predictions empirically. Using health administrative data from 2006 to 2014 and a two-stage estimation strategy, we study the impact of switching from FHG to FHO on the production of a capitated basket of services, after-hours services and nonincentivized services. Our results reveal that switching from the FHG to FHO reduces the production of capitated services to enrolled patients and services to nonenrolled patients by 15% and 5% per annum and increases the production of after-hours and nonincentivized services by 8% and 15% per annum.

An alternate level of care plan: Co-designing components of an intervention with patients, caregivers and providers to address delayed hospital discharge challenges.

ObjectiveTo engage with patients, caregivers and care providers to co‐design components of an intervention that aims to improve delayed hospital discharge experiences.DesignThis is a qualitative study, which entailed working groups and co‐design sessions utilizing World Café and deliberative dialogue techniques to continually refine the intervention.Setting and ParticipantsOur team engaged with 61 participants (patients, caregivers and care providers) in urban and rural communities across Ontario, Canada. A 7‐member Patient and Caregiver Advisory Council participated in all stages of the research.ResultsKey challenges experienced during a delayed discharge by patients, caregivers and care providers were poor communication and a lack of care services. Participants recommended a communication guide to support on‐going conversation between care providers, patients and caregivers. The guide included key topics to cover and questions to ask during initial and on‐going conversations to manage expectations and better understand the priorities and goals of patients and caregivers. Service recommendations included getting out of bed and dressed each day, addressing the psycho‐social needs of patients through tailored activities and having a storyboard at the bedside to facilitate on‐going engagement.Discussion and ConclusionsOur findings outline ways to meaningfully engage patients and caregivers during a delayed hospital discharge. Combining this with a minimal basket of services can potentially facilitate a better care experience and outcomes for patients, their care providers and families.

Institutional context: What elements shape how community occupational therapists think about their clients' care?

Clinical reasoning (CR) is the cognitive process that therapists use to plan, direct, perform and reflect on client care. Linked to intervention efficiency and quality, CR is a core competency that occurs within an institutional context (legal, regulatory, administrative and organisational elements). Because this context can shape how community therapists think about their clients' care, its involvement in their CR could have a major impact on the interventions delivered. However, little is known about this involvement. Our study thus aimed to describe the elements of the institutional context involved in community therapists' CR. From March 2012 to June 2014, we conducted an institutional ethnography (IE) inquiry in three Health and Social Services Centres in Québec (Canada). We observed participants and conducted semi-structured interviews with 10 occupational therapists. We also interviewed 12 secondary key informants (colleagues and managers) and collected administrative documents (n=50). We analysed data using the IE process. Of the 13 elements of the institutional context identified, we found that four are almost constantly involved in participants' CR. These four elements, that is, institutional procedures, organisation's basket of services, occupational therapists' mandate and wait times for their services, restrictively shape CR. Specifically, occupational therapists restrict their representation of the client's situation and exploration of potential solutions to what is possible within the bounds of these four elements. In light of such restrictions on the way they think about their clients' care, therapists should pay close attention to the elements of their own institutional context and how they are involved in their CR. Because of its potentially important impact on the future of professions (e.g. further restrictions on professionals' role, reduced contribution to population health and well-being), this involvement of the institutional context in CR concerns all professionals, be they clinicians, educators, researchers or regulatory college officers.

Considerations concerning CAVAT: what does its “tree amenity value” actually measure?

ABSTRACT CAVAT’s system for amenity tree valuation is based on planting cost, modified by size and several physical and aesthetic factors. It does not represent actual replacement cost. Its adaptation for aesthetic valuation is contentious, partly because of arguable subjective judgements. The supposed mental frame of valuers causes serious miscalculation of unit value, because installation cost is divided by current basal area, not predicted lifetime basal area. Deriving an “annual unit value” offers a way to circumvent this problem. Which basket of services is valued is unclear. The value offers a possible starting point in negotiating compensation, but not “a market price” for amenity trees. While some problems are endemic to expert valuations, others are specific to this system. Identifying them might help in revising the system, to provide a value both rational and reasonable.

Evidence-based preschool-age vision screening: health policy considerations.

BackgroundThere are many causes of visual impairment, and even blindness, which are treatable or at least preventable. Two such conditions are strabismus (crossed-eye, squint) and refractive error (visual image not focused on the most sensitive part of the retina). If these are not detected and corrected at an early age, they can lead to an irreversible impairment known as amblyopia (lazy eye). Pediatric vision screening and subsequent treatment for amblyopia and amblyogenic risk factors are thus key to preventing vision loss. Furthermore, vision screening can detect moderate to high hyperopia, which has been found to be associated with poor school readiness.Evidence-based recommendations call for screening children at 3–5 years of age; they are old enough to cooperate, but still within the window of effective intervention. However, these recommendations have yet to be universally implemented as the standard of care.MethodsThis paper integrates a review of the literature and the international experience of preschool vision screening with the findings from a preliminary feasibility study of expanded screening in Israel to formulate a discussion of the current health policy challenge in Israel and the options for addressing it. The advantages and disadvantages of various venues for vision screening are discussed.FindingsScreening by optometrists in Mother and Child Health Centers, as implemented in a recent pilot project in the Jerusalem District, would allow the most comprehensive testing. Photo-screening in preschools would reach the most children, but at the cost of missing hyperopia (farsightedness). Either approach would probably constitute improvements over the current situation. The relative strengths of the two approaches depends in part on the ability to purchase automatic screening equipment (and the efficacy of that equipment) vs. the ongoing cost of paying trained personnel.ConclusionsFurther research should be conducted in Israel to determine the prevalence of refractive errors, so that best practices can be established for Israel’s population and social needs. In the interim, the Ministry of Health should promptly implement the inclusion of preschool visions screening for children in the approved “basket of services” covered by the National Health Insurance Laws, using photo-screening, including collection of the clinical data.

Dental status, visits, and functional ability and dietary intake of elderly in Israel

BackgroundEpidemiological studies have shown deterioration in dental health accompanying the ageing process. Tooth loss increases with age. Chewing ability is closely correlated with number of natural teeth present: there is a threshold of 20–21 teeth, below which chewing ability declines. The government of Israel is currently considering adding dental treatment for elderly to the basket of services of the National Health Insurance Law. Information on the influence of elderly’s dental health on nutrition and general health status can contribute to the decision making process.MethodsSecondary analysis of data collected on a subsample (N = 1776) of the cross-sectional Mabat Zahav - National Health and Nutrition Survey of the Elderly was done. Intakes of energy, fiber, protein, fruits and vegetables, associations with dental visits, dentures presence and functional ability were analyzed. Linear regression adjusted for confounders was performed.ResultsStatistically significant differences in dietary intake of energy, fiber, protein and vegetables were found between elderly who visited a dentist in the last year and those who did not. Elderly who possessed dentures had lower dietary intakes than their dentate counterparts. Elderly with functional problems such as impaired chewing had worse dietary intakes than the others. This was so after controlling for education, degree of interest in the relationship between nutrition and health and reading the nutrition label.ConclusionsThe findings in our study suggest that those who visited a dentist in the last year, had natural teeth and no denture/s and reported no chewing problems had better dietary intake. The results emphasize the importance of maintaining adequate dental health, preserving natural teeth and regular dental visits in the elderly to assure adequate nutrient status in this age group.

Addressing Malnutrition among Children – An Assessment of Dastak Abhiyan in Madhya Pradesh

Background: The Dastak Abhiyan is considered a pioneer program of Government of Madhya Pradesh and was pilot tested in the month of November 2016. The program offers a basket of services (10 core activities) focused on the reduction of Under 5 mortality Objectives: In this study, we monitored the functioning and the implementation of 10 core activities of the Abhiyan in 4 districts of Madhya Pradesh viz. Jhabua, Sheopur, Raisen, and Bhopal. Methods: The study takes into account modified World Health Organization(WHO)’s 30x7 cluster sampling where 7 households were selected from 30 villages of 4 districts of Madhya Pradesh including 2 tribal and 1 high priority district. Results: We have observed that majority of the Front Line Health Workers (FLWs) were working as per the micro plan. We identified few gaps, such as FLWs missed on carrying out some of the activities viz. Blood Test, Mid Upper Arm Circumference measurement, demonstration of Oral Rehydration Solution preparation, and Handwashing. Conclusion: We found the need to strengthen inter-communication, to customize micro plan in consultation with the Auxiliary Nurse Midwife of that village. Our study also highlighted the need for supportive supervision, post-training assessment for FLWs to assess the knowledge gained by them during the training session.

Canada's efforts to ensure the health and wellbeing of Indigenous peoples

Canada's efforts to ensure the health and wellbeing of Indigenous peoples

Cindy Blackstock: advocate for First Nations children

She has been called “Canada's Martin Luther King”, the “conscience of the nation”, and a “national hero”, but Cindy Blackstock bristles at the accolades. “The only reason my job exists is because racism against First Nations children has been used as a cost-saving measure. I don't want that job to exist—now or ever.” Blackstock is the Executive Director of the First Nations Child and Family Caring Society of Canada, a charity that, for 20 years, has lobbied for First Nations children to have equitable access to health and social welfare services. Canada's time to actBeavers, ice hockey, maple syrup, Mounted Police, peace-keeping. These things conjure Canada in the minds of many. Others will add health to the list, for Canada's public health-care system is one of the oldest and most celebrated in the world and because Canada has ministered to global humanitarian, migration, and medical crises for decades. While Canadian values of solidarity, inclusivity, and diplomacy have found much expression in matters of health, there are clear signs that all of the world now “needs more Canada”. Full-Text PDF Challenges in health equity for Indigenous peoples in CanadaCanada's health-care system, like the country itself, is a complex entity. As the two papers in The Lancet's Series on Canada1,2 make clear, the country's health-care landscape is made up of multiple people, places, and policies with often overlapping—and sometimes conflicting—jurisdictions, priorities, paradigms, and practices. These complexities are rooted in Canada's fairly young colonial history that resulted in a nation comprised of a majority of settler and recent immigrants and their descendants, alongside a steady resurgence of Indigenous populations of First Nations, Inuit, and Métis peoples that are growing in numbers, political acumen, and agency. Full-Text PDF Canada and global health: accelerate leadership nowCanada's celebration in 2017 of 150 years as a nation is a ripe time for reflection on both its own universal health system and the country's global commitments towards universal health coverage (UHC) as articulated in the Sustainable Development Goals (SDGs).1,2 The recognition in the prairie province of Saskatchewan that farmers should not have to sell the farm to pay for their family's health care was the principled pivot point that triggered Canada's march towards UHC in the 1960s. Although it took nearly a century for the Canadian confederation, established in 1867, to achieve UHC, over these past 50 years, from a global perspective, Canada's universal health-care system is viewed as being among the world's best. Full-Text PDF Canada's efforts to ensure the health and wellbeing of Indigenous peoplesIn September, 2017, Prime Minister Justin Trudeau stood before the UN General Assembly and acknowledged that the “failure of successive Canadian governments to respect the rights of Indigenous peoples in Canada is our great shame.”1 For generations, First Nations, Inuit, and Métis peoples in Canada were denied the right to self-determination and subjected to laws, policies, and practices based on domination and assimilation. Indigenous peoples lost control over their own lives. Full-Text PDF Canada's vision for global health and gender equalityA global shift is happening. I see it wherever I go—coffee shops to cabinet meetings to international conferences. We have achieved a critical mass of activists and allies around the world who are fighting for women's rights. The message is clear: the world is ready to make real progress on gender equality, and improve the lives of women and girls. Full-Text PDF Canada's universal health-care system: achieving its potentialAccess to health care based on need rather than ability to pay was the founding principle of the Canadian health-care system. Medicare was born in one province in 1947. It spread across the country through federal cost sharing, and eventually was harmonised through standards in a federal law, the Canada Health Act of 1984. The health-care system is less a true national system than a decentralised collection of provincial and territorial insurance plans covering a narrow basket of services, which are free at the point of care. Full-Text PDF Canada's global health role: supporting equity and global citizenship as a middle powerCanada's history of nation building, combined with its status as a so-called middle power in international affairs, has been translated into an approach to global health that is focused on equity and global citizenship. Canada has often aspired to be a socially progressive force abroad, using alliance building and collective action to exert influence beyond that expected from a country with moderate financial and military resources. Conversely, when Canada has primarily used economic self-interest to define its global role, the country's perceived leadership in global health has diminished. Full-Text PDF