Abstract
The scarcity of Health Human Resources (HHR), regional disparities, and decentralized healthcare systems have profoundly affected health equity in Canada. Adequate HHR allocation is essential for equitable healthcare delivery, and the COVID-19 pandemic has revealed the importance of resilient and culturally diverse organizational HHR. Geography and infrastructure shortcomings aggravate healthcare equity. This study examines the role of innovative technologies in reducing inequity and provides four practice-based examples in different therapeutic areas. Long-term solutions such as collaborative networks, infrastructure improvements, and effective HHR planning can mitigate current challenges. However, in the short and medium terms, advanced medical technologies, digital health, and artificial intelligence can reduce health inequities by improving access, reducing disparities, optimizing resource utilization, and providing skill development opportunities for healthcare professionals.
Introduction
The Canadian healthcare system's operational framework has evolved over the years in response to the emergence of innovative medical and technological advancements and financial constraints. 1 The historical provider-centric system has failed to provide effective, quality care to patients. 2 Consequently, the healthcare system adopted the then-new Triple Aim (TA) framework, which aimed to balance the cost of care and patient experience to achieve better outcomes. 3 TA was replaced by the Quadruple Aim, which incorporated the providers' well-being. 4 The importance of provider well-being was observed during the pandemic, exposing long-standing healthcare shortcomings. 5 Arguably, the pandemic exacerbated two crucial challenges for the healthcare system: Health Human Resources (HHR) and acute and long-term care capacity. 6 Next, the Quintuple Aim introduced equity as the fifth component, realizing that providing high-quality care is impossible without addressing inequity. 7 Quintuple Aim follows the six domains (safe, effective, patient-centred, timely, efficient, and equitable) identified by the (IOM) for healthcare improvement. 8 This study aims to explore the principles of equitable care and provide examples of advanced technologies to mitigate HHR and capacity problems in healthcare.
This study is a descriptive review of the published literature on the theoretical concepts of healthcare access and the factors contributing to equity. The authors conducted a qualitative review of the publications analyzed and used the material to synthesize relevant information for this study.
Healthcare equity and related challenges
The World Health Organization defines equity as the state of being free from avoidable or remediable differences among groups of people, regardless of socioeconomic, demographic, or geographic characteristics. 9 Health inequities encompass more than health determinants and access to resources; they also include inequalities that violate fairness principles. 9 Reducing health inequities is crucial for a healthy society because access to healthcare is a fundamental human right. 10
Research has linked inequity to social determinants of health (e.g., income and living arrangements), and empirical evidence indicates that healthcare delivery is unequally distributed and largely fails to reach the poor and marginalized groups. 11 Although “inequality” and “inequity” are used interchangeably, they differ; inequity refers to a more significant social construct problem related to justice. 12
A major contributor to inequity is the lack of timely access to healthcare, which necessitates that people have the right to (1) get appointments or services within a reasonable timeframe, (2) get complete information about their health, and (3) fully participate in decisions concerning their health, including the right to refuse care. 13
Additionally, researchers have identified three types of delays affecting healthcare access: delay in (1) the decision to seek care; (2) reaching the facility; and (3) receiving care once at the facility. 14 Common factors encompassing all three types of delays are the capability to provide care and the impact of geography.
Health human resources
HHR plays a critical role in addressing healthcare inequity. 15 The main focus of HHR in this study is on clinical team members, including physicians and nurses. Appropriately distributed HHR is crucial for ensuring timely access to healthcare. Research showed that regions with more nurse practitioners have better access to primary care and improved health outcomes. 16 Canadian Institute of Health Information (CIHI) reported that underserved rural regions encounter challenges in recruiting and retaining HHR. 17 The disruptions caused by the pandemic exacerbated existing HHR disparities and underlined the need for a well-prepared and resilient HHR to guarantee equitable healthcare. 18 The increased demand for healthcare services during the pandemic put immense pressure on HHR, resulting in heightened workloads and burnout. 18 Rural areas experienced substantial HHR shortages as they were concentrated in urban areas where the virus impact was initially more severe. 19 HHR had to be redeployed to pandemic response roles, disrupting healthcare delivery and causing delays and cancellations of non-urgent procedures. 19 The HHR redistribution accentuated the importance of having a workforce with adaptable skills and the ability to provide care in various settings. 20 The pandemic also revealed the need for a diverse and culturally competent HHR to cater to the requirements of marginalized communities. 21 Specific populations (e.g., ethnic minorities, Indigenous communities, and low-income people) were disproportionately impacted by the virus due to pre-existing social determinants of health and systemic inequities. 19
Geography and the rural divide
Canada’s vast geography presents unique challenges for accessing healthcare, particularly in rural areas. Statistics Canada defines rural areas by the Index of Remoteness, which is determined by the distance that separates a community from all the population centres in a given travel radius and the population size of these centres. 22 This geographical conundrum affects health equity, as rural residents face hurdles in timely access to care due to distance from healthcare providers and HHR shortages. 23 The CIHI rural health systems model identifies qualitative and quantitative measures in evaluating rural healthcare. 24 This model examines the intricate interaction between geographical and socioeconomic characteristics of the population with surrounding factors (e.g., infrastructure, innovation learning capacity, and care delivery models) that define the unique measures of rural healthcare needs.
A Canadian study demonstrated significant maldistribution of physicians, with rural areas experiencing shortages and urban areas having a surplus. 11 Another study highlighted the HHR recruiting and retaining challenges in rural regions, causing persistent gaps in access to primary and speciality care, contributing to health inequities. 25 Despite initiatives like the rural and northern immigration pilot, 26 and the rural coordination centre of British Columbia, 27 this disparity in HHR distribution persists. Canada’s decentralized healthcare system, where provinces and territories have substantial autonomy in care delivery, further compounds geographical health inequity. 28
Technology as a solution to healthcare inequity
The existing healthcare delivery model is labour-intensive. 29 Training healthcare professionals requires decade-long policies, investments, and planning. However, in the post-pandemic era, healthcare systems require immediate solutions to mitigate the HHR and capacity deficiencies. The most viable and sustainable solution is to expand the use of technology in healthcare. Innovative medical technologies can enhance healthcare efficiency and effectiveness in addressing current deficiencies. 30 Remote Monitoring (RM), Minimally Invasive Surgeries (MISs), Artificial Intelligence (AI), and Robot-Assisted Surgeries (RASs) are a few examples of technologies that can alleviate current problems and improve healthcare equity.
Remote monitoring and telemedicine
RM enables healthcare professionals to monitor patients and provide timely intervention remotely. 31 RM is particularly advantageous for those in remote or underserved areas who encounter difficulties accessing care. Through remote consultations, virtual follow-ups, and continuous patient vital signs monitoring, RM improves specialized care access, minimizes travel, and provides timely interventions despite geographical constraints. 32 RM is especially beneficial for patients with chronic conditions, reducing hospital visits and promoting health equity by offering regular follow-ups without in-person appointments. 31 On a system level, RM optimizes the HCRU by reducing unnecessary hospital visits, minimizing facility strain, and ensuring efficient resource reallocation. The pandemic telemedicine surge has demonstrated RM merits, supporting patients in accessing low-acuity care, such as chronic care management, from home. This approach bridged small hospitals with larger academic centres via telehealth services. A Canadian clinical trial found that the RM group participants had fewer hospitalizations (22% vs. 27%), better pain management, and reduced drug errors. 33
Minimally invasive surgery
Technological strides in surgery, exemplified by laparoscopy and catheter-based procedures, have revolutionized surgical procedures by enabling MIS. 34 One example is Transcatheter Cardiac Valve Replacement (TAVR), a game-changer for Aortic Valve Stenosis (AS) treatment. AS, if untreated, has a poor prognosis and survival. 35 Conventional AS treatment is open-heart surgery, which may be unsuitable for certain patients due to a high surgical risk. International guidelines endorse TAVR across all surgical risk profiles. 36 A systematic review shows AS patients opt for surgery to alleviate symptoms and improve their function, preferring procedures with shorter Length of Hospital Stay (LOS) and recovery. 37 In another study, 79.5% of AS patients favoured TAVR attributes, including reduced invasiveness, faster recovery, and time to their usual quality of life. 38 For the healthcare system, TAVR provides shorter hospital and intensive care unit stays, lower complication rates, and reduced Healthcare Resource Utilization (HCRU), resulting in optimized HHR deployment and capacity management. 35 By a less invasive alternative, TAVR ensures equitable access to lifesaving interventions for those who cannot or prefer not to undergo open-heart surgery. 35
Another example of MIS in stroke is Mechanical Thrombectomy (MT), which has transformed the ischaemic stroke outcomes trajectory. A Canadian trial showed a statistically significant difference in the rate of functional independence between MT and standard of care. 39 Yet inequitable access to stroke care exists. 40 A study reported that 87.3% of Canadians reside within an hour's drive of a stroke centre, only 69.2% had access to a centre operating seven days a week, and 3.4% reached cross-provincial border centres faster. Over 50% of the sites lacked stroke neurologists and did not meet the best management practices. 41 Another study showed that 31% of stroke patients received 24 hours of cardiac rhythm monitoring, while <1% received prolonged monitoring. 42 The one-hour drive metric is misleading. While rural residents can access computed tomography (85%), thrombolysis (81%), stroke units (68%), and stroke prevention clinics (74%) within an hour’s drive, only 32% can access MT within the same time frame, perpetuating lifesaving technology-access inequities for Canadian stroke patients. 43
Artificial intelligence
AI technologies are rapidly integrated into medicine, impacting radiology, diagnostics, and surgical procedures like colonoscopy. 44 Colorectal Cancer (CRC) is the third-most deadly and fourth-most commonly diagnosed cancer. 45 Some polyps are overlooked during a colonoscopy, accounting for 25% of interval CRC cases. 46 The Adenoma Detection Rate (ADR) is a quality indicator for colonoscopy. 47 Higher ADR improves the hazard ratio and cancer-related mortality. 48 AI-enhanced colonoscopy (e.g., Computer-Aided Detection (CADe)) provides real-time endoscopic image analysis, improving ADR. 49 Colonoscopy outcomes depend on clinicians’ experience. Patients with access to larger centres with experienced clinicians tend to have better outcomes. 50 A Canadian population-based CRC study reported that the median survival for urban, rural, and suburban populations was 104, 94, and 83 months, respectively, and the residence location was a significant predictor of survival. 51 CADe can improve health equity by democratizing access to enhanced diagnostic results. Moreover, CADe's performance is likely to improve further through ongoing annotated data inputs, increasing the accuracy of diagnosis, enhancing healthcare system efficiency, and reducing cost. 44
Surgical robots
RAS has transformed MIS, improving optical visualization, surgical manoeuvring, and tissue resection.
52
Today, RAS, particularly in urology, is preferred by both patients and surgeons.
53
In the United States, 85% of prostatectomies and 50% of hysterectomies are performed robotically.54,55 The clinical benefits of RAS in various therapeutic fields have been documented, including reduced mortality and perioperative complications, decreased blood transfusion, and a shorter LOS.
56
Moreover, robotic techniques have a shorter learning curve than laparoscopy, providing consistent precision and improving surgeon experience and operator comfort.
57
RAS provides skill development opportunities to clinicians, allowing them to offer specialized care remotely, which is particularly important in underserved areas with a shortage of subspeciality surgeons. By enhancing the skills of healthcare professionals through RAS training and utilization, access to specialized care can be democratized, thereby reducing disparities in healthcare (Figure 1). Schematic scores of select advanced healthcare technologies for the quintuple aim framework.
Discussion
This study assessed the current challenges in equitable care delivery, emphasizing on HHR and geographic distribution. We also provide examples of advanced technologies as readily available solutions to address coverage and equitable access in some areas of healthcare. These technologies were selected as they broadly resemble the patient journey in the healthcare system from primary care triage to referral to tertiary and complex speciality care. Our assessment aligns with that reported in the current literature.
The Tanahashi healthcare service model, introduced by the World Health Organization, evaluates health system access and coverage through three metrics that reflect the different stages of care: availability, accessibility, and acceptability. Acceptability is a factor in initial contact with the health system, continued utilization, and quality. Actual coverage is measured by contact and effectiveness. 58 In this model, the first critical step is allocating resources, particularly the workforce, which limits the population's maximum capacity and availability of services. During the pandemic, we observed disruptions in primary, acute, and long-term care due to the overwhelming demand and shortage of resources, including HHR. The second step is to determine the location of the services that must be within a reasonable reach for which they are intended. Canada’s large landmass and population distribution inherently cause inequities in healthcare delivery. The third stage is the contact and interaction between the provider and the user. The number of people interacting with a service measures its output. The ratio of this number to the size of the target population provides a measure of coverage, which can be referred to as contact coverage.
The HHR shortage in Canada indicates a low service output, which is unacceptable in urban and rural areas. Contact between the service provider and the user does not always ensure successful intervention or effective service. Therefore, the Tanahashi model considers another stage in the service provision process, where a service is appraised as satisfactory based on specific criteria. 58 The number of people who have received satisfactory service is another measurement of service output, and the coverage based on this output is referred to as effectiveness coverage. Indeed, this could arguably be a key indicator of equity in healthcare. The output measure (e.g., the number of interactions with the system) is misleading as the quality of care and outcomes may differ.
Multiple short-term (3-5 years) or long-term (+10 years) strategies are required to overcome healthcare inequity, including strategies to address HHR, infrastructure, and enabling technologies. Numerous strategies have been piloted to mitigate HHR issues. Interprofessional collaboration to boost coordinated care, 59 digital solutions, 60 and mobile healthcare units 61 to provide primary care, screening, and diagnostic services are examples of short-term local and regional strategies. However, the long-term impact of these strategies remains unclear. Investing in reliable broadband infrastructure in rural areas, 62 improving transportation infrastructure, 63 and ensuring equitable HHR distribution, 64 are examples of long-term solutions for minimizing the geographic distance between patients and healthcare providers.
Innovative medical technologies can provide sustainable and efficient solutions to mitigate short- and medium-term challenges. MIS techniques and RAS can improve the availability and efficiency of surgical intervention, particularly in underserved regions. These procedures often result in smaller incisions, faster recovery, and shorter LOS than conventional open surgeries. 55 Consequently, patients have improved access to specialized surgical care, irrespective of their geographic location. MIS offers equivalent or better clinical outcomes than open surgeries while minimizing the burden on patients regarding travel time and costs. 65 MIS requires shorter operating room times, fewer hospital resources, and reduced postoperative care needs, allowing centres to optimize their HHR and bed capacity and allocate resources efficiently. 66 While the cost-effectiveness and affordability of TAVR in Canada have been demonstrated, the false perception that TAVR is expensive impedes its optimal use. 35 Healthcare decision-makers hesitate to increase TAVR funding or reallocate cardiac surgery budget to TAVR, contradicting the Quintuple Aim and patient empowerment principles. 67
Another significant but less-discussed advantage of MIS is skill enhancement and training. Ensuring that surgeons in rural areas are trained in these procedures can increase the availability of local specialized surgical services and facilitate healthcare professionals' retention in these regions. 68
Similarly, RAS enables surgeons with advanced robotic skills through virtual reality and remote control of robots to provide guidance and mentorship to local surgeons during procedures, offering real-time advice and making high-quality surgical procedures accessible regardless of geographical barriers. 57 By offering safer and more efficient surgical procedures, RAS contributes to equitable healthcare delivery by ensuring consistent standards of care regardless of geographic location. 69 Comparable to MIS, introducing RAS in underserved areas provides opportunities for local healthcare professionals to receive specialized training and develop advanced skills, establishing a surgical team, decreasing reliance on external surgeons, and improving local access to advanced surgical care. 69 For patients, RAS can alleviate the burden of long-distance travel and associated costs, improve patient comfort, reduce financial strain, and enhance health equity by providing equal access to advanced surgical interventions. 70
The rapid integration of AI into healthcare technologies is redefining and reshaping healthcare delivery and medicine. The consensus is that AI will improve healthcare outcomes through improved specificity and accuracy, especially in diagnostics. 44 However, it is plausible that AI would help efficiency in the healthcare system by eliminating routine and administrative work for the clinical team, helping the HHR issues. 71
One of the risks associated with AI is the “black box” approach, which can hinder the widespread use of AI in healthcare. 72 Unlike conventional analytical methods, non-linear analysis, especially deep learning models, lacks transparency, making it difficult to understand how the model makes a particular decision. Nevertheless, AI-enhanced technologies require rigorous safety and feasibility studies like other medical technologies. 44
Addressing health inequities in Canada requires a multifaceted approach that considers HHR, geography, and decentralized healthcare. The current HHR crisis has exacerbated the challenge of equitable healthcare delivery. Adequate HHR distribution, allocation, and strategies to address workforce shortages are long-term. In contrast, advanced technologies are readily available solutions that can potentially reduce health inequities in the short term. With rapid enhancements in technology (e.g., integration of AI), it is foreseeable that technologies will further improve access to healthcare and alleviate inequity. However, implementing advanced technology in the healthcare system is not without challenges. Adopting advanced technology requires planning, adequate structure (e.g., information technology), training, and change management, which competes with resource allocation in other parts of the healthcare system.
Conclusion
Achieving health equity in Canada requires a comprehensive and collaborative effort. Addressing HHR-related challenges, such as training and recruiting healthcare professionals, requires long-term policies. In short and medium terms, leveraging advanced medical and surgical technologies and digital solutions can democratize access to specialized healthcare services and contribute to equitable healthcare delivery.
Footnotes
Authors' contributions
All authors contributed to the study's conception and design. Hamid Sadri and Neil Fraser developed the idea and conceptualized the research question and methodology. Hamid Sadri wrote the first draft of the manuscript, and Neil Fraser critically reviewed the manuscript. All authors read and approved the final manuscript.
Declaration of conflicting interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Hamid Sadri is an employee of Medtronic, the manufacturer of medical technologies. Neil Fraser is a retired executive of Medtronic.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics approval
This study is a synthesis of current knowledge. Ethics review board approval was not required.
