Canada

The Military Health Services of Canada

HISTORY 

The Royal Canadian Medical Service (RCMS) is almost as old as Canada itself. One of the first requirements of the new Dominion in 1867 was to develop its Militia, and with it a medical service, to replace the British garrisons that were scheduled to be withdrawn. As such, there was a gradual evolution from individually recruited regimental doctors and stretcher-bearers to the centralized organization that now serves the entire Canadian Armed Forces (CAF).[1] Equally historically significant is the Royal Canadian Dental Corps (RCDC). Formed in 1915, the RCDC has served in both World Wars, Korea and Afghanistan as well as numerous peacekeeping and humanitarian operations. Both the RCMS and the RCDC have storied histories and unique identities. 

On 2 May 1969, a year after the Royal Canadian Navy, the Canadian Army and the Royal Canadian Air Force were integrated to form the CAF, the Canadian Forces Medical Service was authorized as a personnel branch of the CAF. On 1 September 1969, the RCDC became the Dental Branch of the CAF, followed shortly thereafter on 27 August 1971 with the RCMS being designated the Medical Branch. In 1995, the Canadian Forces Medical and Dental Services were united under the Surgeon General as the Canadian Forces Health Services. In 2013, both the Medical and Dental Branches were both officially re-designated as RCMS and RCDC respectively.

NATIONAL CONTEXT AND SUMMARY

Canada: Overview and Geostrategic position

Geographically, with a total landmass of almost 10 million square kilometres, Canada is the second-largest country in the world. Bordered by three oceans: Pacific, Atlantic and Arctic, it also has the world’s longest coastline. 

In the southern part of the country, Canada shares a roughly 9,000 km border with the United States of America (U.S). The vast majority of Canada’s population of 38 million live within a few hundred kilometres of the U.S. border, leaving much of Canada’s land mass uninhabited. 

Peaceful relations with the U.S. have persisted since the War of 1812 and, given the close proximity of Canada to the U.S., much of the burden of security is shared with this global superpower. 

Organization of the Ministry of Defence and Armed Forces

The Governor General of Canada is the Commander-in-Chief of the Canadian Armed Forces (CAF). The Department of National Defence (DND) is headed by the Minister of National Defence (MND), a federal Cabinet Minister. The Deputy Minister of National Defence is the Department’s senior civil servant. The CAF is headed by the Chief of the Defence Staff (CDS), Canada’s senior serving officer. Each has different responsibilities:

The Governor General is responsible for appointing the CDS, on the recommendation of the Prime Minister, for awarding military honours, presenting colours to CAF regiments, approving new military badges and insignia and signing commissioning scripts.

The MND presides over the Department and over all matters relating to national defence.

The Deputy Minister is responsible for the articulation of the department’s corporate vision and in particular for policy, resources, interdepartmental coordination and international defence relations.

The CDS is responsible for command, control and administration of the CAF and military strategy, plans and requirements and advises cabinet, as required.

National Health System

The organization of Canada's health care system is largely determined by the Canadian Constitution, in which roles and responsibilities are divided between the federal, provincial and territorial governments. The provincial and territorial governments have most of the responsibility for delivering health and other social services. The federal government is also responsible for some delivery of services for certain groups of people. The Canada Health Act is Canada’s federal legislation for delivering publicly funded health care. The Canada Health Act is based on the guiding principles of accessibility, portability, universality, comprehensiveness and public administration. Under the Canada Health Act, primary care doctors, specialists, hospitals and dental surgery are all covered by provincial insurance programs[2].

There is more to health than the health care system. The responsibility for public health, which includes sanitation, infectious diseases and related education, is shared between the three orders of government: federal, provincial/territorial and local or municipal. However, these services are generally delivered at the provincial/territorial and local levels. [3]

Canadian Forces Health Services (CFHS)

The Surgeon General (SG) is the Medical Officer who is the professional head of the Canadian Forces Health Services (CFHS). They control all clinical/scientific health practices (excluding Dental practices), and are the senior CAF, CDS and Minister’s adviser on all matters related to health. Regular Force CAF members are excluded from provincial and territorial responsibilities under the Canada Health Act legislation, requiring the CAF to have its own health care system to deliver health care to CAF members within CAF medical clinics by uniformed clinicians, public servants or contracted care providers. These medical and dental personnel provide most aspects of care including surgery, treatment of disease and illness, medical laboratory services, dental and pharmaceutical services, and mental health and psychosocial services. Where care cannot be provided internally, members are outsourced to external providers and institutions.

Command of health services unit is currently held by Health Services Division Commander who is responsible for the delivery of health care to CAF members. The CFHS consists of personnel from approximately 48 health occupations and specialties. Their objective is to promote, protect and restore the health of both in-garrison and deployed forces. CFHS provides medical and dental services to approximately 95,000 CAF personnel in-garrison and on deployed operations (including the Primary Reserve), along with public servants and civilians when directed by the Minister of National Defence.

Download: Map-Canadian Forces Health Services

ORGANIZATIONAL STRUCTURE

CFHS is a distinct formation of the CAF and is headquartered in Ottawa. The SG is currently double-hatted as the Director General Health Services is the medical advisor to the CDS and reports administratively to the Commander Military Personnel Command (CMPC) and functionally to the Chief Military Personnel. The Health Services Division Commander is responsible for the operationalization of Health Programs and reports to CMPC.

CFHS currently provides health services in two distinct contexts: on deployments within Canada and around the world and at home, on our Bases and Wings. CFHS Regular Force field units include 1 Canadian Field Hospital and three regular force Field Ambulances (Fd Amb). A self-sufficient deployable Role 3 health care facility, 1 Cdn Fd Hosp has a complement of approximately 250 personnel representing more than 20 different clinical and support trades to include Medical Technicians, Medical Specialist Physicians, Nurses, Physician Assistants, administrative and logistical support staff. Military specialists associated with the Field Hospital maintain their clinical competencies by being embedded in civilian hospitals. Alternatively, a Fd Ambs’ primary operational role is Role 1 care on operations and exercises, as well as staging casualties on the battlefield and medical evacuation within forward areas of the operational theatre.

CAF Health Services Centres (HSCs) are found in 33 locations and several more detachments across Canada. All HSCs serve to provide medical and dental care to support CAF readiness.  CFHS also maintains an international footprint of three HSCs to support CAF members and dependents who may be posted to international locations. 

The CFHS Reserve (HS Res) is a Reserve component integrated into the CFHS command structure. It is organized into two functional groups – 10 Res Fd Ambs (Res Fd Ambs), and the 1 Canadian Field Hospital Detachment Ottawa (1 Cdn Fd Hosp Det Ott). Res Fd Ambs force generate trained personnel to support, augment and sustain the CFHS, provide health services support to Canada’s Primary Reserve (Naval, Army, and Air Force Reserves), and conduct community outreach activities. 1 Cdn Fd Hosp Det Ott specialist clinicians provide depth and breadth to the CFHS clinical capability on international operations and in military clinics within Canada. 

Other key components of the CFHS are the Central Medical Equipment Depot (CMED), which provides medical re-supply to CFHS, the CF Environmental Medicine Establishment (CFEME), which conducts research focused on extreme environments, offers specialized clinician training and conducts medical fitness assessments, the Canadian Forces Health Services Training Centre (CF H Svcs TC) which provides military specific training for CFHS health professionals and qualification programs for unique professions, such as Medical Technicians (Med Tech) and Reserve Force Medical Assistants. 

Overview to linkage between the Ministry of Defence, Joint Forces and the Army, Navy and Air Force

Dedicated health advisory and planning cells support the Royal Canadian Navy, the Canadian Army, the Royal Canadian Air Force, the Canadian Joint Operations Command, the Strategic Joint Staff, the Canadian Special Operations Forces Command and the CAF Regional Joint Task Forces. Most Health Services personnel belong to CFHS, which acts as a joint enabler, allocating health services personnel to the separate environments (Navy, Army and Air Force), as required. Some exceptions include Health Services personnel posted to Special Operations Forces and onboard ships. The Surgeon General maintains clinical professional technical authority for these personnel.

Unique characteristics of internal relationships in the military health system

Canadian Forces Health Services has a robust Professional Technical Network. Command can be bestowed on all Health Services trades but Professional Technical control always rests with senior physicians, dentists and practice leaders for medical and dental care. 

CFHS medical and dental clinics within Canada use public service employees and contractors to augment military personnel for the delivery of health care. These clinics focus on ambulatory care. Most secondary and specialist care is obtained through the civilian sector. 

Download: CFHS Current Functional Organizational Structure

FIRM BASE HEALTH SYSTEM 

Currently, CFHS comprises 43 units and 82 detachments. Our health care team comprises of more than 6000 positions, made up of Military members, Public Service employees, and contracted health care providers. One of CFHS primary responsibility is to deliver safe, high quality health care to its entitled personnel in their official primary language of choice (French or English).  Primary health care services available to CAF members include (but are not limited to) physiotherapy, laboratory services, diagnostic imaging, dental services, pharmacy, preventative medicine and case management. Mental Health and Psychosocial services are also provided via a comprehensive system of delivery with interdisciplinary clinics employing psychiatrists, MH nurses, psychologists, social workers, addiction counsellors and clinical chaplains.

Healthcare Beneficiaries 

Beneficiaries of the CAF health system include the Regular Force, the Special Force, the eligible Reserve Force, eligible forces from the North Atlantic Treaty Organization (NATO) in Canada, and any other military force or civilian as directed by the Minister of National Defence. A dependant of a member of the Regular Force, of the eligible Reserve Force or of an eligible NATO force may be provided with medical care by the CAF military health system in prescribed circumstances.

Veterans who have left active duty or reserve employment receive their health care services and benefits from their respective province or territory of residence, with augmentation from Veteran Affairs Canada (VAC), as required. Although such entitlements and benefits fall outside the scope of the military health system, collaboration between CFHS, civilian health care systems and VAC enables a safe transfer of care for releasing CAF members. 

MILITARY MEDICAL RESEARCH AND INNOVATION 

 Through the Surgeon General Health Research and Innovation Program (SGHRIP), CFHS conducts significant basic and applied militarily-relevant health research to advance evidence-informed best practice, and to support the decision-making process. The program is achieved by way of collaborative projects with Defence Research and Development Canada (DRDC), other partners within the DND and other government departments, military health research organizations, allies, Canadian industry, and academia. 

A variety of professional partnerships support ongoing DND Science and Technology initiatives and are vital to the CFHS research program. They also ensure the CAF is on the cutting edge of new technologies and health care practices. CFHS personnel also participate in several multi-national research efforts. Some examples include the Health, Medicine, and Protection area committee in NATO's Science and Technology Organization and several of its Research Task Groups, along with The Technical Cooperation Program (TTCP) technical panels on Military Medicine

CFHS personnel continue to publish peer-reviewed articles and technical reports annually. Presently, the Surgeon General has five areas of research that have been deemed a high priority for internal study and partnership research.   These areas include developing a framework to assess, track and anticipate the consequences of COVID-19, the prevention and treatment of MSK injuries, enhancing mental resilience training for our Road to Mental Readiness (R2MR) program, using internal Health Services data to access health trends and inform decision making, and conduct women’s health research in fields such as reproductive health, occupational exposures, mental health, injury prevention and post-injury rehabilitation.

OPERATIONAL CAPABILITIES 

Canadian doctrine for operational medical support aligns NATO’s medical support doctrine as articulated in Allied Joint Publication - 4.10 Allied Joint Medical Support Doctrine and its subordinate publications. CFHS is frequently called upon to deliver essential health services support to CAF operations both domestically and abroad. During larger and enduring operations, CFHS can provide on-site primary and emergency health services, including initial surgery and post-operative care, short-term surgical and medical in-patient care, as well as diagnostic imaging, dental, pharmacy, and laboratory services. Robust force health protection capabilities are deployed to identify and mitigate health threats arising from operational, occupational, industrial, and environmental health hazards. 

Specialized capabilities within CFHS may also include the CF Forensic Odontology Response Team (CF FORT), which comprises of 12 Dental Officers and Dental Technicians on 48 hour notice to move and whose mission is to aid in the identification of fallen soldiers. In collaboration with the Royal Canadian Air Force, CFHS also has the capability to provide both tactical and strategic aeromedical evacuation (AE) using a variety of rotary and fixed wing aircraft. Bio-containment (isolation) for the AE of patients diagnosed with a highly communicable disease is available either through deployment of individual isolation units or the aeromedical bio-containment evacuation system. CFHS is also a contributing partner to the CAF Disaster Assistance Response Team (DART). The DART is activated by the Canadian government to help when natural disasters and emergencies happen around the world and when the local response effort is overwhelmed or incapacitated. The DART can provide water purification services, primary medical care and engineering support during a humanitarian crisis. 

Does the military have any standing domestic and international tasks or operations?

For a complete and up-to-date list of standing domestic and international tasks or operations, please visit Military operations - Canada.ca

How are new medical equipment or capabilities procured? 

Medical equipment capabilities are centrally governed within the CFHS. The development of new capabilities is done within the CAF and DND in concert with applicable stakeholders, via established systems of governance and capability development tools. Procurement of new medical equipment capabilities is effected by governmental Procurement Directorates within the DND and Public Services and Procurement Canada (PSPC).
 

How are medical logistics organized and managed during operations? 

On CAF Operations, medical logistics are handled differently depending on the scale of the mission. For the largest operations, there will usually be a Forward Medical Equipment Depot (FMED) stood up as well as a CAF Pharmacy. The FMED receives medical items from the Central Medical Equipment Depot (CMED) in Canada and stores them for dissemination forward to CAF unit medical stations (UMS) and surgical installations when appropriate. For medium-sized operations, the deployed Pharmacist (Pharm O) is responsible for managing and storing the medical supplies and requesting orders through CMED. If a moderately-sized operation has no Pharmacist deployed, the Senior Medical Authority (SMA) is responsible for managing the medical supply. On small operations, deploying clinicians generally bring medical kits with them that they receive from their home units, either through CMED or produced locally by their supporting base pharmacy.

In the majority of new operations, the CAF uses medical kits, which are built and stored in advance in order to allow rapid deployment and ensure that all medical assets required to meet the needs of the operation are deployed. Resupply of medical supplies is pushed by CMED on a cyclical basis based on requirements, which are dictated by the Pharm O or SMA. The CAF will occasionally leverage other methods of resupply, including local means of medical supply procurement when time or shipping constraints prevent pushing of supplies from Canada and collaboration with allied nations to receive and distribute medical supplies on joint operations.

Describe innovations or lessons from the experience of providing military medical support on operations. This might include links to publicly available books or other sources. 

The collection of lessons learned (LL) for the CAF is conducted in accordance with the Defence Administrative Orders and Directives (DAOD) 8010-0 – Lesson Learned. The LL program is defined in the document Canadian Forces Joint Publication – CFJP A2 Lessons Learned and can be found here. As of 1 February 2022, the Defence Lessons Learned System (DLLS) became available to all employees as a centralized repository to collect, store, and share LL. The DLLS also facilitates the approval process for observations and Lessons Finding Reports to support change management and implementation of best practices. DLLS access is intended for all DND employees – both civilian and military. 

MILITARY MEDICAL PERSONNEL

Military Medical Recruitment 

The Canadian Forces Recruiting Group (CFRG) is responsible for recruitment of all CAF occupations including the health services occupations, both officer and non-commissioned members. There are six (6) Canadian Forces Recruiting Centres (CFRC) and 26 Detachments located in cities and towns across Canada to accomplish this aim. Embedded within the CFRG are Specialist Health Services Recruiting Officers and administrative staff that focus on recruiting efforts for Health Services personnel. These Specialist Recruiting Officers provide applicant support throughout the recruitment process. They also give subsidized education and direct entry briefings at universities and colleges and attend various conferences (e.g., medical, dental, nursing, pharmacy, paramedic, etc.) at which they provide information to conference delegates on career opportunities with the CFHS. Recruiting to CFHS occupations is also accomplished from within the CAF through Occupational Transfers, Component Transfers (from the Reserves to the Regular Force) and via Direct Entry or in-service selection programs. 

Recruiting of Primary Reserve Force (Res F) personnel falls under the direction and guidance of the Director of Health Service Reserves. An annual Strategic Intake Plan is developed in consultation with tactical level units as well as the Directorate of Health Services Personnel. Recruiting is done primarily at the tactical level which each unit having a Recruiting Officer responsible for attraction. 

Individual Education and Training 

The majority of CFHS clinician education is sourced from civilian health education institutions using a variety of programs for both officers and non-commissioned members. This includes both baseline education programs, such as bachelor degrees, as well as specialized training programs for nurses and doctors. Some professional training programs are offered through the CFHSTC, such as Medical Technician and Medical Assistant training.

Postgraduate Education and Advanced Training

Postgraduate education is available for many CFHS occupations through a competitive sponsorship process. Education opportunities are sourced from Canadian and international universities as well as allied military schools. For several of our occupations, such as Social Work Officer, Physiotherapy Officer and Pharmacy Officer, the entry standard for enrolment requires a master’s level or higher education.

Maintenance of Clinical Readiness Program

The Maintenance of Clinical Readiness Program (MCRP) is designed to support the CAF mandate of maintaining a ready medical force by providing the military healthcare providers opportunities to maintain and/or enhance clinical competencies that cannot be maintained at their normal place of duty. Collaboration and partnership with civilian organizations are critical to the military healthcare providers to access placement opportunities and activities relevant to the MCRP.

MILITARY MEDICAL TRAINING

How are basic soldiering skills and medical specialist training delivered?

CFHS personnel attend a recruit training establishment to complete basic training and learn foundational soldiering skills. Recruit training programs emphasize basic military skills, weapons handling, and first aid. Basic military medical training and associated skills are learned through a variety of training programs offered at the CFHSTC.

Is there mandatory individual training in military skills such as weapon handling, CBRN protection and first aid? 

CFHS personnel must be trained to ensure they are capable of performing both general and all CFHS duties and tasks assigned. As part of annual Personnel Readiness Verifications (aPRV), CFHS personnel are required to conduct training that includes pistol, C7, Chemical, Biological, Radiological, Nuclear (CBRN) and, when appropriate, standard first aid. 

Are there specific military medical training institutions? E.g. field training centre, military medical school, military nursing school etc.? 

The CFHS has two training centres: the Canadian Forces Health Service Training Centre (CFHSTC) and Canadian Forces Environmental Medicine Establishment (CFEME). CFHSTC, located at CFB Borden, Ontario is the primary training establishment for Regular and Reserve Force members of the CFHS.  The role of CFHSTC is to conduct individual military health services occupational training.  

CFEME, located in Toronto, Ontario, is committed to supporting development, engineering, and evaluation of human performance and protective systems for Air applications in collaboration with Defence Research and Development Canada (DRDC) Toronto. CFEME personnel have a significant depth of knowledge and offer a wide variety of services in: Aeronautical Engineering, Aviation Life Support Equipment, and Human Factors. CFEME courses include Basic and Advanced Dive Medicine, Basic Aviation Medicine, Operational Flight Surgeon Course and Submarine Medicine.

Simulation Training

The CFHS also has one Medical Simulation Centre, located in Valcartier, Quebec, which provides simulation training for Med Techs. Simulation training challenges participants and allows them to repetitively practice emergent care in a simulated operational setting in a controlled learning environment. There are two Trauma Training Centres located in Vancouver, British Columbia and Montreal, Quebec. These centres also deliver formalized simulation training programs in support of the MCRP and pre-deployment training for Medical Officers, Nursing Officers and Physicians Assistants.  

How is the military collectively trained and validated to meet readiness? 

CAF members are expected to deploy in various types of environment, which are often unstable, volatile and hostile.  As such, deploying CAF members are expected to be highly trained, fit and able to adapt to changing environments while executing a wide spectrum of activities. 

Collective training (CT) activities are planned, managed and coordinated to support the mission of the DND and the CAF.  The CT of units and task forces are conducted to ensure that they can successfully operate anywhere on the spectrum of conflict, from humanitarian operations in support of civil authorities and other government departments, up to full combat, with allies when appropriate. CT is intended to facilitate the achievement of joint, interagency and combined capabilities that are identified by the CDS and operational level commanders, and that are generated by environmental chiefs of staff (ECS). The CAF also conducts Theatre Mission Specific Training (TMST) which provides personnel with special mission requirements not part of individual and collective training. TMST may be planned and dovetailed with individual and collective training.

CIVIL-MILITARY RELATIONS

The CFHS maintains a Civil-Military Cooperation (CIMIC) team at the strategic and operational levels with the mandate of fostering relationships between CFHS and external organizations such as health networks, hospitals and professional regulating bodies. They also maintain a vast network of contacts with health professionals in all levels of government. While its primary mandate is the care of CAF members, CFHS is integrated within national and provincial/territorial health systems through strategic alliances, memoranda of understanding, local arrangements, and a general spirit of cooperation and goodwill. CFHS also enjoys close relationships with allied military medical organizations in NATO and around the world. The CAF health system is accredited by Accreditation Canada, an independent national healthcare quality authority that is internationally recognized for setting standards of excellence.

As a pan-Canadian health system with significant national and international responsibilities, the CFHS maintains strategic links with a host of provincial and federal agencies in order to execute its assigned mission and tasks at home and abroad. Militarily, the CFHS also enjoys a close professional relationship with allied military medical organizations in NATO and around the world. 

Given that the majority of the formal arrangements for co-ordination/collaboration between the Canadian civilian and military health systems are in support of training and education opportunities and CAF is a major employer of health service professionals, the CFHS enjoys excellent relations with many Canadian professional associations and regulators. Through its efforts to “professionalize” the management aspects of its business and the quality of its service, the CFHS has established a close bond with the Canadian College of Health Leaders and the Canadian Society of Physician Leaders. 

Civil-military medical co-ordination in response to national emergencies 

In Canada, emergencies are managed first at the local level with municipal responses. If further assistance is needed at the municipal level, it is requested by the province or territory. If the emergency escalates beyond provincial capabilities, the province or territory seeks assistance from the federal government. The Government of Canada responds under the Federal Emergency Response Plan (FERP) with the Minister of Public Safety as the lead department for national crisis response. 

A request for federal assistance (RFA) is the process by which a province or territory formally requests support from the federal government in their emergency response efforts. The RFA involves official communication between a provincial, territorial or federal department and Public Safety. It outlines the need for federal assistance to respond to an emergency when the jurisdiction needs additional resources, including requests for CAF support.

For example, for pandemic-related requests, the Government of Canada worked with the Public Health Agency of Canada (PHAC), the CAF, Indigenous Services Canada, the Canadian Red Cross and others, as required. CFHS CIMIC cells can also deploy trained Liaison Officers (LOs), particularly at the tactical level where the CAF may be engaged with local governments and their first responders and emergency managers. 

Civil-military medical co-ordination as part of the military contribution to humanitarian and disaster assistance 

Medical Support to Deployed Operations (MSDO) includes the deployed medical activities that support the ability of the CAF to conduct both domestic and overseas operations, whether they involve combat, humanitarian or disaster relief missions. These services may be delivered by CFHS personnel, contracted civilian health care providers, locally-procured medical services, and/or through partnerships with other international military health services.

Chemical Biological Radiological Nuclear and Explosives (CBRNE) Emergencies

 In order to enhance and sustain Canada's resilience to CBRNE events, a specialized unit within the CAF, the Canadian Joint Incident Response Unit (CJIRU), provides a rapid chemical, biological, radiological, and nuclear (CBRN) response for special operations missions.

Although decontamination is among CJIRU’s capabilities, they focus first and foremost on detecting, identifying and mitigating CBRNE risks. In Canada, CJIRU responds in cooperation with the Royal Canadian Mounted Police (RCMP) and PHAC during CBRN operations.

[1] Taken from: Canadian Forces Medical Service: Introduction to its History and Heritage (mil.ca)

[2] Taken from: Canadian Health Care: Public Health Care Providers (canadian-healthcare.org)

[3] Taken from: Canada's Health Care System - Canada.ca 

(status: 31 January 2024)