A/HRC/41/34/Add.2 33. The levels of government involved in the Canadian health-care system suggest complexities for the State to be accountable under the right-to-health framework. This was highlighted by the Committee on Economic, Social and Cultural Rights in 1998 when it regretted that “by according virtually unfettered discretion to provincial governments in relation to social rights, the Government of Canada has created a situation in which Covenant standards can be undermined and effective accountability has been radically reduced”.16 34. The Special Rapporteur recalls that, even with different health-care schemes at the provincial/territorial levels, the obligation to protect, respect and fulfil the right to health remains with Canada as a whole. He offers two recommendations to help Canada comply with its international obligations: (a) include human rights criteria in the existing criteria for health federal transfers under the Canada Health Transfer; and (b) consider adopting a rights-based national health-care framework/strategy for the whole country. 35. The right-to-health framework provides concrete standards, such as nondiscrimination, acceptability, quality, informed consent or participation, that can be added to existing criteria on federal financial transfers under the Canada Health Transfer, so that those funds may be withheld or reduced by the Government of Canada when human rights are not protected, respected and/or fulfilled by the provincial/territorial governments. 1. Identified remaining gaps in health-care delivery 36. The Special Rapporteur commends the strong focus on public health, universality, equality and fairness of the Canadian health-care system. He however identifies four types of remaining challenges: (a) Gaps in health goods and services that are not covered by provinces or territories, mainly linked to current requirements in the national legal framework; (b) Discrepancies in gaining access to quality health care by provinces and territories owing to the federal division of health-care responsibilities; (c) Gaps faced by groups in vulnerable situations owing to the barriers they continue to encounter while gaining access to health-care services, including indigenous peoples; (d) Lack of parity between mental and physical health. 37. Regarding the first gap, the Canada Health Act does not require provincial or territorial governments to include services that are provided outside of hospitals by healthcare personnel other than doctors, such as physiotherapy, psychotherapy and occupational therapy. In Quebec, for example, access to the latter requires first seeing a physician. The Special Rapporteur further received information about challenges regarding waiting lists, online registrations to consult primary-care doctors for the first time and changing clinics in Quebec. 38. Provincial/territorial governments are also not required to cover prescription medication, older persons’ care, mental health and “addiction services”,17 dental and vision care or rehabilitation services, among others. Those types of services are, in some cases, covered by private health insurance plans that employers or unions offer for their respective constituencies, and in other cases they are paid for through out-of-pocket payments. 39. The current coverage of medicines differs significantly by province and territory, considering the Canada Health Act does not establish requirements for the public funding of out-of-hospital pharmaceuticals, nor a homogenous pharmacare system. Each province 16 17 8 See E/C.12/1/Add.31, para. 19. “Addiction services” is used in Canada for services that address the “problematic use of substances”, defined as “the use of substances which affect the central nervous system and alter a person’s mood, thinking and/or behaviour” (www.canada.ca/en/health-canada/services/substance-use/canadian-drugssubstances-strategy/strengthening-canada-approach-substance-use-issue.html#a2). The United Nations system has adopted a common position to the world drug problem whereby it chooses not to use the terms “substance” and “addiction” (https://digitallibrary.un.org/record/3792232?ln=en).