Chapter 2
WAYS OF KNOWING: HEALTTH
POLICY AND HEALTH STUDIES
INTRODUCTION: THE SCOPE OF HEALTH STUDIES AND
HEALTH POLICY
The scope of health studies and health policy has traditionally been narrowly
focused on clinical health care interventions provided by health care professions
such as medicine, nursing, physiotherapy, and occupational therapy. In the
early to mid-20th century, health studies focused on treatments carried out
by physicians and other health professionals and their effects on the health of
individuals. Consistent with this biomedical focus, the emphasis was on the
organization and delivery of clinical health care services. Much of these health
study activities examined what occurs in hospital settings.
But there is also a tradition of studying health and health care issues in
the social sciences that has existed alongside that of the health sciences (Teeple,
2000, 2006). In the mid-19th century, Chadwick, Virchow, and Enges began
to link the health of populations to living and working conditions. Socioogy
of health, illness, and medicine grew out of this tradition, and this is now
a standard undergraduate course offered in most sociologY programs across
Canada. In this approach, social scientists have applied broader social science
Concepts
to
elucidate the organization and
delivery of medical services, as well
health and their impact
the social--or non-medical-determinants of
ashealth.
This broader scope has also been concerned
on
with understanding the
determinants of health that exist outside of the clinical or hospital setting.
concerned
have identified critical questions about health
and social forces
WIth understanding and explicating how economic, political, as the health of
as well
nce the organization of the health care system
& Bryant, 2015).
c population (Bryant, Raphael, & Rioux, 2010; Raphael
and soclal
also linked structures such as public policies and political
ocial scientists
nave
Ons
with
political ideology
to
explain the organization
33
of health
care
Health P'olicy in
Canada
34
Ways of Knowing
and hcalth outcomes. They attcmpt to make explicit that which is implici
and
perhaps masked in public policies, such as attitudes or biases that may includ
racism. scxism. homophobia, and so on. An important focus of this literat
is
how societal institutions perpetuate political. cconomic, and social inequalities
in power and infuencc (Grabb, 2002).
As a result of thesc social scicnce influences, the study of health is no
Figure 2.1: The Major Means of Power, Structures of Domination,
and Bases for Social Inequality
Means of Power
Control of Material
Resources, Production
Control of Human
Resaurves, People
Control of Ideas.
Knowleig
longer limited to strict cxperimental studies ot how one or more factors predics
Seructures ot
the incidence of a discase or its treatment and outcome. The scope of health
Economic Structure
Political Structure
ldeologicd Structures
Domination:
(extraction. production.
or Srate (executive.
religion. mass mecdia.
studies now includes the determinants of health, the perceptions of health held
Substructures
hnance, commerce, etc.)
judiciury. civil service.
education and scence.
police, military, etc.
etc.)
by individuals. and identifying public policy approaches by which health Gan
Bases for Social
Incqualicy (closure.
exclusion. exploitation)
be improved and maintained.
As one such example of social science analysis, Figure 2.1 identifes the
societal structures that underlie social inequalities (Grabb, 2002). Grabb
states: "Social inequality can refer to any of the differences between people
(or the socially defined positions they occupy) that are consequential for the
lives they lead, more particularly, for the right or opportunities they cxercise
and the rewards or privileges they enjoy" (p. 2). The model suggests that
the components making up the cconomic structure of a sociery, consisting
of the market (i.e., the systems of production, finance, and exchange), the
political structure of the state (i.c., governments and the civil service), and
associated ideological structures (comprising religious belicfs, the mass
media, cducational systems, and others), play important roles in shaping the
distribution of resources within a society.
These structures are of such importance in the organization and operation
of sociery that it would also be expected that these societal structures would
shape the organization of the health care system and related public policy
domains that infuence health-in other words, health policy. This indeed
appears to be the case. The analysis of how these societal structures-the
market and other cconomic forces, governments, and ideological concepts
infuence health policy is a primary goal of this book.
Since the 1970s,
growing evidence has supported the belief that health-and
maintenance-is more complex than can be discerned from
only examin
physical health and treating disease (\World Health
1986).
ItS
suggests that health
concept influenced
by a
1. Ownership. wealth.
income
2. Fducation
3.Occupation
Non-class bases:
4. Sex or gender
5. Race. cthniciry,
language
6. Spatial location
(country, region
rural-urban
residence)
Age
8. Religion
9. "Party Athiliation"
Soure Grabb, E. (2002). Theories of social inequalir (p. 224). Toronto: Harcourt Canada.
clinical health care (Epp, 1986; Evans, Barer, & Marmor, 1994: Lalonde, 1974).
The social sciences contributed to this concept of health as multidimensional
and have offered critical insights into the organization and delivery of health care
services and the factors that promote health (Teeple. 2006. 2010).
The proliferation of undergraduate and graduate health studies programs
at Canadian universities in recent years is testament to the growing interest
in health, and in studying health trom diverse perspectives. Some of these
REDEFINING HEALTH
the evidence
Class-related bases:
Organization,
Moreovc
onal
best be understood as a multidimensiot
of
range of factors that fall outside the traditional
can
spne
programs attempt to link traditional health science studies with social
science theory in order to raise critical questions about the impact of societal
institutions and forces that shape public policies, and thereby intluence the
health of populations.
The social science disciplines, particularly sociology and political science,
have contributed the most compelling insights to the discipline of healch studies
Health Policy in
Canada
36
Ways of Knowing
1
(Armstrong, Armstrong, & Coburn, 2001). They have done so by identii
and investigating critical questions about the different meanings of health ing
a
the influence of public policy upon the organization and
care services, and on the other factors that affct health.
In
delivery
of
Figure 2.2: Social Determinants of Health
heali
particular,
the political economy perspective has been
concerned with
identifying the economic, political, and social structures (that is, the societal
institutions and forces) that influence health (Coburn, 2010).
Social
Material
Structure
Factors
Work
These
analyse
take two forms. The first focuses on the
organization of the health care systemm.
What role do the economic system, the state, and societal
ideologies
shaping the form of the health care system? There are a number of play in
political
economy perspectives. To the questions about power and
political ideolopy
asked by mainstream
add
political economy,
questions concerning
other attributes,
on
the
impact
of
Social
Environment
Paychological
Health
Behaviours
other
political economy perspectives
gender, race, and disability, amono
opportunities for health and health outcomes.
organization of society in general infuence
Second, how does the
non-health care/non-medical determinants of
Pathophysiological
Changes
the
disadvantage
for others. These social determinants include
living conditions such as income
housing availability and quality, access to education, nutritious food, and
health care, and the influence of gender, among others
(Raphael, 2008).
A political economy
perspective therefore directs attention to a broad and
diverse range of health issues that include how the
production and distribution
of economic, political, and social resources
shape the health care system, as well
as the broader determinants of health. These
analyses can also help explain how
individuals make certain assumptions about their
society and their own health,
and their expectations of what health care services and
health-supporting
public policies should be in place (Coburn, 2010).
WAYS OF THINKING ABOUT HEALTH
Both the traditional health sciences and the social sciences have
developed
various ways of thinking about health. These
paradigms range from identiyng
individual biomedical and behavioural risk factors for
specific health conditions
such as the idea that
smoking leads to lung cancer, to broader paradigms that
emphasize how social environments and
health
public policies shape
and Immune
Responses
Organ Impairment
Early Life
the health of
populations? A
political economy analysis of health is very helpful in answering this question,
It can capture the political dynamics that
shape and interact with economic
and social conditions to produce social advantage for some and
(Blac
Smith, 1992; Labonte, 1993). More
specifically, ways of thinking about hea
Brain
Neuroendocrine
Genes
Well-Being
Morbidity
Mortality
Culture
Source: Brunner, E.,
&RG. Wilkinson
&
Marmot, M.G. (2006). Social
organization, stress, and health.
(Eds.), Social determinants
In
M.G. Marmot
of health (p. 9). Oxford: Oxford University Press.
range from traditional concerns about clinical health care to an
emphasis on the
economic, political, and social forces that
shape the organization and delivery
of health care services and related
public policies that determine the health of
a
population (Raphael, 2008).
Understanding these different conceptions of health is important
because these ideas can
strongly influence how health care services are
organized and delivered. They can also infuence how health-related
public
policy is defined and implemented.
Four major
paradigms for understanding health are available, and these
have influenced Canadian health
policy to varying
are the
medical,
behavioural/lifestyle, socio-environmental,
degrees. They
and structurall
critical
paradigms. Labonte defined the first three, and Raphael defined the structural/
paradigm (Labonte, 1993; Raphael, 2007). Each paradigm leads to
diferent definitions of health
problems, different strategies for improving
health, different target groups, and the
delegation of responsibility to different
people within society. In some models, health
professionals are responsible for
critical
N
38
Health Policy
in
anada
39
Ways of Knowing
maintaining health, while in others, responsibility falls to individual citizene
In still others, the primary responsibility falls to citizens vwho become organized
into political and social movements to advocate on health issues.
the medical paradigm
attention is focused upon these activities. Additionally,
and the
manner by which the media, policy-makers,
dominant
the
is clearly
about the meaning of determinants of health and the means by
think
public
et
2007).
which health can be promoted (Gasher et al., 2007; Hayes al.,
The Medical Paradigm
The medical paradigm is the traditional biomedical paradigm that defines
health as the absence of disease and disabilitry (Labonte, 1993). The
health issues are defined in terms of disease categories and physiological
factors, such as a statistical deviation from the population average. Disease
primar
risk
categories are professionally defined and include cardiovascular disease
diabetes, HIV/AIDS, obesiry, arthritis, mental disorders, and hypertension,
among others. Moreover, the medical paradigm considers disease as having
an independent existence from the individual's social environment and ideas
(H. Wilson, 2000). It also embodies a cause-and-effect reasoning, such that
condition A does something to B, which results in effect C. This paradigm
also focuses on the presence of risk factors for these same disease
For example, obesity becomes a concern for those working in this approach
because it is hypothesized as increasing the risk of developing cardiovascular
categories
disease, high blood pressure, and diabetes, among other chronic diseases.
The Behavioural/Lifestyle Paradigm
individualized
an
The behavioural o r lifestyle paradigm also provides
in t e r m s
defined
is
Health
primarily
1993).
health
(Labonte,
concept of
of individual energy, functional ability, and disease-preventing lifestyles.
risk factors such as
The primary health problems are seen as behavioural
exercise.
of
lack
and
habits,
Drug o r alcohol abuse,
poor dietary
coping skills, and lack of life skills
smoking.
poor
are
also identified
as
important
health problems in this paradigm.
behaviours
strategies o r interventions for changing these risk
and advocacy for public policies that
are health education, social marketing,
These activities can include smoking
and
changes.
lifestyle
promote
support
The principal
construction of
bans, prohibition on the use of trans fats in food products, and
such
bicycle paths to promote active lifestyles (Labonte, 1993). The targets for
interventions are groups of individuals deemed to be at high risk for health
Defining health problems in terms of disease categories and risk factors
highlights the need for professionally defined medical interventions to reduce
individual risk and manage symptoms and disease. The medical paradigm is
focused on physical symptoms and clinical outcomes. The interventions can
responsible for delivering these interventions are employees of
and regional public health departments; chronic disease advocacy
groups such as the Canadian Cancer Society and the Lung Association;
be surgery, drugs, and other therapies that usually require a referral froma
and municipal, provincial, territorial, and federal governments. Ulimately.
physician. They also include medically managed behavioural change through
patient compliance with diet and exercise regimens, and ongoing patient
education related to these factors.
taking these risk-reduction measures.
The targets of such interventions are individuals identified as aflicted
with a disease or those at higher risk for a disease. The general intervention
approach is highly individualized. Physicians, nurses, and other allied health
professionals are responsible for delivering these interventions to individuals
at a time. The
monitoring of individuals and their biomedical indicators is
one
important part of this process.
The organization and
delivery of health care services are clearly organized
within the parameters of the medical
paradigm. Emphasis is on the detection
of disease and treatment
by health care professionals. It is not surprising. given
the vast
expenditure on health care services, that governmental and pubiC
an
problems, usually children and youth.
Those
municipal
however, individuals are seen as responsible for maintaining their health by
All three levels of government in Canada engage in social marketing
that promotes individual responsibility for maintaining health. For example,
public health departments develop anti-smoking campaigns that target youth,
particularly adolescent girls. These campaigns exhort adolescents not to smoke,
and focus on strategies to resist peer pressure to smoke. Many health authorities
engage in such lifestyle campaigns; an example of such a campaign is provided
in the first part of Box 2.1.
Surveys indicate that the Canadian public clearly subscribes to many
tenets of the behavioural/lifestyle paradigm. When asked what may be the
best ways to promote health, the overwhelming tendency is to provide
behavioural/lifestyle
responses concerned with
diet, exercise, and tobacco
alt
Flir
y in
uad,
Box 2,11 Disferent Approaches to 10 Tips for Better Health
in a prpudatinn utay et al, 201 3), hor tsample, may detracs from broaer
joanro that inluenee health, uuh as incomerelad health inequalities.
Alehennghh the behaviural/lifesryle paradign shares suome similarities
wih the raditional nrdical paraldign, it emphasizes the preventinn rather
han the tneatment of rzioting health andition, Sro alvncares may argjue
hat they are enpovering penple to take umol of and imprave their healeh.
olew alustaw ed diet with plemty d fuit and wppnaldes,
Keep dhyodally ao tivr,
Manag otros luy. r
entnple, talking thinga tlteugh sned making tinne
telax
ol disease, WLile there is soune elflort to provide environnental suppors
I yon daiuk ahohol, do sn in muleration
C v r u in te bll1, tel protedt hikdren fuom ounlbn,
7.
0 "make the healuhy huiee, the easy choiee" (Koelen
lindesröm,
2005) (eg, he impunition of sin taxes, changing lood oerings in schol
Maie saler sek.
Tale up (uer eelug oppounlles,
aleterias, itl provleliug other inenmives to "heal1hy living"). governnent
interventiona aln o
e a a l e on the melor follow ile 1 liglhway ( ule.
10. a n
2:
the 1irt Aid AlC b1 alrways,
Sn lal Deteniaa
e
breatling,
pernal esponeil»iliuy
cireaulaton,
Heer Ilealuh
10 lipa lon
ho noted ave, they do n primarily within an individualist approach
(1aonte, 1996, 1997), Individuals are considered responsible for adopring
healuhy bebaviours ia promote guul health, therety reducing their risk
improve indlividual belhavionrs by emplhanizing
lr healh.
The Socio-environmental Paradigm
Iheonio onviumenal pivaeligm
u have paw puet
Ilealh be delinecd an a pmitive concept ln tems ol conectedesw to fannily
lrtend, atnd one'a comnlty. It is coemed with people tuavingcontrol over
live in dannp. low qualiuy houuslug
Me alble to allhvd u
po
on a
foegn
thelr livex and having ilhe abiliuy to engage in ativitles that are impornant or
lolieday and atulathw
Iuave eaniug lor tlhem, t diveets attentlon to counity amd so ietal fac tors
PMtie not losug your jobs and dhoni become enplovrl,
Take
up
all benelios
yol are
entitted
t , if
you a e
mnpkoved, netel,
ele ke ton disaltel.
,
D t live
next
tu
a
is
indiviluad rdlk factonn suneh an eholesterol or bloond puesure (Laonte, 199).
D o t wok in a Meelul, low mid niuNal jol,
Mn
alo termed the nmaterialist paradlign
comcened witlh riak conditons uch as pverty or low income tather than
busy uajot rnnd
or t
duollul dan ton
benelit/asrln
10. len how tw ill n the comples housio
odeainte.
los Ieloe you becone lonelesw dted
applih atn
hat uppot health. I teatlh prolbtene ave delined in tem of pye hown ial anl
ste ler envirnental visk lautous suh as puverny, witiug in a distrt witl
hiplh industvlal polutton, iuelathon, suestul envionments, and hazandous
llving and working conlitios, anong others. his appunauh tan be eenA
onsistent wiuh te second paut of ox .
While attenim is lireetel to the lauper
ewionnenos
in whih inlivislhnats
lIve, sene asputs of an ndlvalualled panaulig ane puesent. Ihe pamadijgn
Cphasdeew builtng sonial suppores for indivituals t ope wiuh pvbdems i
their lves. Ioinug organisathous sunh as o u n v rnws n lheing wih
fauly anmdliiends provile
nuans
tor
oping.
lhe primauy
ineventions
onoed by this patalign inuhude snall group devolopment, sonmity
UNe (atndulian lopulatin lealh laitiative, 004), lhe experts i
slevelopuenm, valitan ruiklinge politieal action and anay and wwica
wih an eyptuasts on odesien, lhe curnen iuue
lhauge (l abonte, 1900),
indvidualist approach
to
health. the tous on mapping the exten
ofodewil
Healh Policy
in
Canada
Ways of Knowing
3
The target
ofthese interventions is ultimatcly high-risk environments."The
socio-environmental paradigm recognizes that the organization ofcommunitie
and societies shapes healelh and the importance of developing political and
economic policies in support of health. Key agents of change are considlerecd t
be citizens, social development and welfare organizations, political movement
such as the environmental and social justice movements, and political parties.
This paradigm, however, docs not explicitly dircct attention to the influence of
larger cconomic, political, and social forces that shape the local environments
that infuence hcalth.
al/racial)
and social democratic
political parties
are seen as
the
catalysts
or such mobilization and promoting public policies in support of health.
Implications for Health Policy
when onc considers the decisions governments make about health, one has to
consider which dominant paradigm of health is at play. One way to ascertain the
dominant paradigm of a jurisdiction is to consider what attention governments
give to various ways of promoting health. It should come as no surprise that
in Canada, primary attention is given to the medical and behavioural/lifestyle
The Structural/Critical Paradigm
paradigms. Why this
The structural/critical paradigm-also termed neo-materialism-is distinguished
by its explicit concern with the organization of society, and how it organizes
and distributes social and economic resources within a population (Raphael,
2007). The strucrural/critical paradigm defines health in terms of an unequal
distribution and control of economic and social power and resources within a
society. The sources of this unequal distribution are attributed to the political
ideology held by governing parties and an unequal distribution of political power
(Armstrong, Armstrong, & Coburn, 2001; Coburn, 2006). An important focus
of this approach is challenging the dominance of certain groups, such as the
scope of health
is the
case
policy constitutes
and the
implications
much of the
content
for understanding the
of this book.
Ways of understanding the world are essential for understanding how
knowledge exists in difterent forms, how these forms shape ways of thinking
about healch, and how knowledge can be used by those attempting to influence
health research and the health policy process. How these actors perceive or
understand knowledge also influences how they use it in their activities.
Moreover, the dominant knowledge approach infuences how policy-makers
and elected representatives decide which forms of knowledge-or evidenceare appropriate areas tor health policy activity.
corporate sector.
There are two features of this paradigm that have relevance for
understanding health policy. These features are the roles of political ideology
and political power in shaping the organization and delivery of health care
services in a society. How does political ideology and the unequal distribution
of resources and power determine the form of health care? Who gets to control
Box 2.2: A Larger Focus: Ways of Understanding the World
how these institutions operate?
The second focus of the critical/structural paradigm is on examining how
governments' health policy? What processes lead to privileging certain cypes
a sociery organizes the production and distribution of social and economic
(i.e., income, employment, housing, and education) that shape
health (Armstrong, Armstrong, & Coburn, 2001). The paradigm most closely
resources
related
this
paradigm is the political economy approach.
paradigm, there is focus on the collective whole society, not
the individual, the instrument for
change. Particular attention is paid to the
policy change process. Interventions or strategies for change involve mobilizing
the population for
political action to bring about desired public policy changes.
Labour and other social movements
(e.g., anti-poverty, feminist, labour, and
to
In this
a
as
or
Understanding world views and how they shape public policy development
raises some important questions: How do certain assumptions infuence
of understanding over others in the health policy change proces How does
the research and policy development process in the health area reftect these
difering approaches?
Ihese considerations lead to the question: How do epistemological and
political assumptions influence the creation and dissemination of knowledge
to influence governments' health policies? What processes lead to privileging
certain types of knowledge over orhers in the health policy change process
How does the research and policy developnment process in the health
reflect these differing epistemological approaches?
areta
Health Policy in
anada
44
Ways of Knowing
knowledge about the world 3t
Perspectives
also
known as world views or paradigms. A knowledge paradigm can be de6
fined
beliefs or assumptions about knowledge and how it is
as a set of basic
what constitutes
on
created
(Guba & Lincoln. 1994). More importantly, a paradigm sets parameters.
n
what can be known. A
paradigm consists of three components: ontolon
blogy,
epistemology, and methodology.
Ontology: Ontology refers to the form in which reality and its objects
Ontology defines
considered.
what
can
be known
underpinnings
re
said to exist. There are widely different views of what constirutes the nature
of
the world, and this is particularly the case when issues such as health and heal
policy are
of these various
It is important to identify the epistemological assumptions
these
have to say about health and health care. Since
what
and
they
theories
health care and healththe
how
world,
view
a
including
of
theories reflect
it is essential to explicitly consider their
related public policy, should be,
and implications (Burrell & Morgan, 1979).
(Guba, 1990), E
or
example, the ontology of the medical paradigm described above is that eality
consists of biomedical and physiological indicators of cell, organ, and body
svStems functioning. Patterns of bodily functioning are driven by natural laws and
mechanisms. In the health sciences, this view is clearly dominant and reflects the
understandings held by most health care professionals. The notion of realitywhar
health is and how to promote it-held by the other health paradigms (behavioural
are
different.
lifestyle, socio-environmental, and structural/critical) very
to how the inquirer-that is, the one
refers
Epistemologg: Epistemology
who wishes to understand the world-creates
nurse, or social scientist)
UNDERLYING THE APPROACHES
SOCIAL THEORY
TO HEALTH
Social theory can support the
various
sections
approaches to health. The following
offers
are particularly insightful. Each
theories that
will examine three social
with individualist orientations
different perspective, some
and some socially based,
analysis,
Positivism
(as well
as
or
to
health,
or
a
micro-
are:
macro-analysis. The three main theories
structural functionalism)
short discussion of symbolic interactionism)
Critical social science (including political economy)
Interpretivism (with
a
(doctor,
phenomena through research and experience
approaches that can be used to learn about
What are the appropriate
the methodology of objective observation
use
one
Should
health?
or
the world
should knowledee
and experimentation developed in the natural sciences? Or,
of
individuals
who are
the
personal experiences
be gained though understanding
most affected by health issues? Perhaps knowledge can be gained by understanding
knowledge about health
or
other
research
and
the societal structures that shape the distribution of economic, political,
in
values
do
role
What
play shaping our
social resources among the population.
therefore,
attention?
of
what
is
Epistemology,
and determining
worthy
inquiries
how
knovwledge creation process, since it shapes
and understood.
acquired
knowledge
to acquire
Methodology: Methodology is about the tool kit employed
that focus
kit
can contain experimental methodologies
The
tool
knowledge.
the lived
on observation of the world, interactive approaches that examine
social
which
in
the
ways
experiences of people, or critical analyses that consider
represents
a
key aspect
is believed
of the
to
be
institutions shape the distribution of resources.
All of these ways of understanding the world-through ontolog%
epistemology, and methodology-will shape our health care and profounaly
affect health-related public policy action and public policy efforts to improv
and maintain health.
Positivism/Rationalism
Positivism is
a
philosophy
that
states
that the
only
authentic
knowledge
is
from positive
scientific knowledge,
scientific method. It
affirmation of theories through strict adherence to the
laws or axioms (Davoudi,
begins with immediate and concrete shifts to general
and identifying
cornerstone of positivism is hypothesis-testing
The
2012).
Traditional positivism holds that
causal
and that such
relationships, especially
knowledge
can c o m e
only
relationships.
both natural phenomena and human behaviour can best be explained through
the
physics, for example, Newton's laws of motion explain
as planets or falling apples (Brunner, 1991).
such
objects
the
The positivist approach emphasizes rational and linear concepts to explain
universal laws. In
action of inanimate
world with a focus on the observable and concrete.
science is to predict and control conditions (Park, 1993;
The aim
of positivist
Guba, 1990). Knowledge is conceived as "bottom-up experience" (a posteriori)
physical and biological sciences and much of the
on the
organized within this approach. There is an emphasis
to search for
is
of
The
criteria of reliability, validity, and objectivity.
goal inquiry
truth, logic, generalizability, originality, and relevance (Albaek, 1995).
(Davoudi, 2012, p. 3). The
health sciences
are
Health Policy in
Canad
6
Ways of Knowing
of Positivism
Box 2.3: The Beliefs
and
Box 2.4: Positivism
The essential beliefs of positivism as applied to knowledge and inquiry are: (
there is an external world that exists independent of human interpretarion;
and (2)
sensory
about the world
objective knowledge
experience. Usually these experiences
can
are
acquired through dira
rect
identified and interpreted
be
within the framework ofthe experimental scientific merthod (Fishman, 1991).
Phenomena that cannot be observed directly through either experience
observation are excluded from this definition of credible knowledge.
or
Policy Analysis
attempt
into the policymaking process
The introduction of positivism
traditional science. In the positivist-rationalist policy
like
more
it
to make
with rational
as incongruent and competing
is
paradigm, politics perceived
Whereas
1990; Jones & McBeth, 2010).
1995;
Gagnon,
(Albaek,
action
reason,
to objective and open inquiry,
devotion
driven
as
seen
by
science can be
does
therefore
and
and
interests,
concerned with power
and truth, politics is
and objective inquiry. Thus,
scientific
of
claims
rationality
the
not adhere to
to
science are considered by s o m e as essential
the methods and process of
and development a purely rational process.
was an
making public policy analysis
Positivism has been the dominant paradigm in social sciences and public
the case in health policy-related
policy studies, and this has especially been
studies. It informs quantitative research. Posicivism, applied to public poliay
analysis, depends on empirical testing of quantitative predictions that are
for
universal truths
logically inferred from hypotheses. It involves quest
trends, and conditions (Burawoy, 2011).
identification
the
patterns,
of
through
of general principles that
Thus, knowledge creation involves developing a set
a
can explain and predict events. Why shouldnt these scientific methods, argue
health and health care, and the public
positivists, be applied to understanding
their
form?
policy processes that shape
One reason they should not is that positivism holds that science is neutral
and denies the influence of values-and politics on inquiry (Wilson, 1983b).
in
t also neglects the study of power and fails to consider how inequalities
and the
shape the definition of what constitutes credible knowledge
by which such knowledge can be obtained and applied. Positivism,
In this
to state it bluntly, implicitly accepts the status quo (Woodill, 1992).
social
and
reinforce
inequalities.
to
is
it
economic,
political,
thought
way,
have
Interpretations of the link berween knowledge, health, and health policy
(Wilson
traditionaly been informed by the positivist knowledge paradigm
power
means
Limitations of Positivism
the c o n t e x t in which
phenomena separately from
"context
can be described as
that
a
they naturally exist or ocur, process
the primary weaknesses of
Indeed,
Guba,
1985).
&
stripping" (Lincoln
about social reality and its need
stem from its linear assumptions
Positivism tends
to examine
positivism
that shapes the phenomenon being investigated (Bryant,
to r e m o v e all context
Research is primarily about determining
2001; Burawoy, 2011; Feilzer, 2010).
studies consider the impact
c
o
n
s
t
a
n
t
and
fixed
processes take. Few
the form these
context o n the phenomenon
of the broader economic, political, and social
clinical health sciences and
chosen to be of interest. This is evident in the
Positivism
the lifestyle-related behavioural approach to disease prevention.
and
biomedical
the
in
embedded
individualism
the
supports and reinforces
There is little consideration of the implications for
behavioural
paradigms.
health in general and health inequalities in particular.
Another
aspect of positivism is the emphasis
important
of evidence
as
referring
to
experimental
on a
restrictive
evidence, and also
This makes examining economic, political, and social forces and how they
understanding
2009;
quantitative research design to obtain this evidence (Bambra,
for
Phoenix et al., 2013). This has restricted what can be said about what works,
influence knowledge development and application somewhat difficult (Albaek,
example,
19836). The positivist paradigm grew out of the
1995; Gagnon, 1990).
physical and natural sciences.
deductive
to
It shifts the
reduce health
focus
to
inequalities
or
improve the health of a population.
or
as pharmaceutical, medical,
downstream factors, such
other individual-level
interventions, rather than structural
that lead to these inequalities in health outconmes.
or
societal factors
Health Policy
in
Can
4)
Wayy of Knowing
the asiumption of a single
assumptions about recality-and
lity
the many complex factors
to
thc
analyst
the only truth-may blind
(Fcilzcr. 2010: Mills. 1959). In addition, thc patad
social
Lincar
as
phenomena
shape
usually does not consider the importance of power relations in shaping social
reality and policy devclopment. In the hcalth policy ficld, it limits the focg
indicators and behaviou
and understanding to biomedical and physiological
at the individual level. These understandin
is
focus
The
factors.
usually
risk
fit in with individualist interpretations. Positivism depoliticizes issues with i
dings
back
Linking
lifestyle paradigms
the earlier discussion, the medical and behaviouralt
discussed earlier, which emphasize individual risk
to
facto
are informed primarily h
and regimens that shape individual behaviours,
to
understand disease and it
the positivist approach. These approaches prefer
and
prevention
in
terms
of individual
narrow,
risk factors
(Labonte,
cause-and-effect
They seek to discover predictable, usually
The concern with measuring and quantifying
19931
factors
of Positivism for the Health Sciences and
health
the positivist tradition because it
emphasizes relationships
and health
berween observable biomedical and behavioural risk factors
continues
and
discoveries
outcomes. Positivist research made significant
a
for
range of seriOUS
causes and treatments
to be
in
important
identifying
acute and chronic medical conditions.
But this is a distinctively depoliticized approach, as it emphasizes
ODyectivity. It is also expert-driven, as exemplified by top-down authoritativ
In the health sciences, it is assumed that health can
maintained through medical interventions and by individuals
research
paradigms.
following tne
Fecommendations of physicians, public health educators, and others whou
deemed to be "experts" on appropria
health
policy activities focus
positivist approach
or
the
to
knwlcdge.
root c a u s e s
of social
issues
mcans
above others, a process known as the
forms of knowledge
it delegitimizes other forms of
time,
At the s a m e
knowledge.
stories
as personal
perspectives
approach
and lived
health
from
experience, thereby shutting
policy
debates.
The
more
legitimization of
knowledge.
out s o m e
traditional
such
aternative
positivist
vulnerable populations.
has also been criticized for excluding
their social and economic marginalization.
thereby
exacerbating
Poverty and
Box 2.5:
Poverty Is Main
By W. Kondro
Heart Disease
Predictor of Heart
Poverty
is
a
on
various medical interventions.
medical and lifestyle gimens. Similarl
the capacity
to
quantify or measure inpa
predictor ot
greater
smoking, obesity,
sociologist says.
researchers,
Despite the limitations of the positivist approach,
value the research
health
analysts
and
policy
science professionals,
many
in
people's
to a
lived experiences
Disease, Says
Canadian
Report
The Lancet
Health Policy Sectors
out
be oriented
They tend
critical analyses of
dismissive of knowledge derived from
inequaliry and can be
their
ability to observe
emphasize
structural social relations. P'olicy analysts may
while holding their
health
abour
policy
impartially and develop theory
other
appraising relevant data and
2012). This
values at bay (Rathbun.
traditional approach, therefore, may privilege
The
evidence without prejudice.
and
and health inequalities.
carried
to
relationships
individual risk
interventions on medical conditions refle
specifying the impact of medical
of the positivist paradigm. These approaches further
many assumptions
address broader determinants of health
minimize and detract from efforts to
Attractiveness
not to examine
some
value-free claims.
treatment
Policy-makers also tend
stress,
In
a
or
heart disease than risk tactors such
blood cholesterol concentrations,
review of
more
than 100 studies
of health
on
Dennis
a
the
as
Canadian
causcs
of
Raphael (York
policy
heart disease, associate professor
"The economic and social conditions
University, Toronto, Canada) suggests:
t r e a t m e n t s and
live their lives, rather than medical
under which
pcople
whether they develop
are the major tactors determining
the Centre
disease." The report was published on May 3 by
to
approaches
for Social Justice, a Toronto-based advocacy group. Lifestyle
to curb smoking
as
such
programmes
improvement of cardiovascular health,
lifestyle
choices,
cardiovascular
said in an interview. They have
obesity, are counterproductive, Raphael
distribution, community
the negative etkect of pushing issues like income
table. Poor people
services, and public transportation otf the health-policy
or
end up
blaming
because it diverts
"rhats harmtul
themselves for their heart disease and
heart diseasc,
their
to
contributors
these main
people from
and the adoption
lare] material deprivation, psychosocial stress,
a result of that stress.
as
unhealthy behaviours (like using drugs)
which
ot
Healh Policy
in
anada
Ways of Knowing
Is Good for Our Hearts," which is vo
yet
Raphacl's report. "Social Justicc
some 22% of life ycars
a pecr-reviewed journal, suggests
in
be
to
published
a
Statistics
Canada
cxtrapolation)
to
lost before age 75 ycars (according
differences. Were all Canadians' ratcs of dearh
are because of income
those living in the wealthiest quintil
from cardiovascular disease cqual to
of neighbourhoods, there would be 6366 fewer deaths each year from
cardiovascular disease," says Raphael.
The poor are at greater risk of developing heart disease because of "social
exclusion," Raphacl argues. "Individuals who suffer from material deprivation
have greater exposures to negative events such as hunger and lack of quality
food, poor quality of housing, inadequate cdothing, and poor environmental
conditions at home and work. In addition, individuals sufering from material
deprivation also have less exposures to positive resources such as education,
books, newspapers, and other stimulating resources, attendance at cultural
events, opportunities for recreation and other leisure activities," he says.
Some of the political remedies Raphael advocates are: higher welfare and
unemployment insurance outlays; improved pay equity; establishment of a
national guaranteed minimum income; stronger antidiscrimination legislation;
higher taxes on the wealthy, including an inheritance tax; a national housing
strategy; and creation of national day care and pharmacare programmes.
He also suggests "directing attention to the health needs of immigrants and
paying attention to the unfavourable socioeconomic position of many groups
and the particular difficulties many new Canadians face in accessing health
and other care services."
The report "Social Justice is Good for Our Hearts" is available online at
www.socialjustice.org/pdfs/JusticeGoodHearts.pdf.
identifies prediction as an asset of positivism and quantitative research. In contrast,
to policy analysis, considers
Fischer (2003), a proponent of alternative approaches
social constructions. Weimer and
qualitative rescarch critical because "tacts
Fischer recognize the value of the opposing paradigm, but the debate only considers
the
interpretivist/constructivist dualism.
Post-positivism-sometimes termcd critical realism-represents a rejection
positivist versus
of
a number of the key
features. Ontologically, both
tenets
of positivism, but
they also
sharea number of
post-positivism and positivism consider reality
that is external and can be studied (Phoenix et al., 2013). Epistemologically,
is considered to be objective. Post-positivism, however, considers
chat human measurement and instruments are inherently faulty, and
researchers cannot execute research outside of their own biases about social and
health phenomena. This tenet highlights that no single method or perspective
ful essence of external reality. While post-positivism, like
can capture the
posicivism, stresses empirical evidence to support hypotheses, objectivity is an
ideal rather than an imperative of research. Multi- or mixed-method research
design is a feature of post-positivist research.
Post-positivist and critical policy analysts criticize positivist policy analysis for
being focused on the use of systematic methods, developing testable hypotheses,
knowledge
and relying on statistical analysis. Sabatier (1988), a proponent of positivist policy
analysis, calls for rigorous criteria, including clearly defined concepts, verifable
hypotheses, and falsification. It is important to note that not all post-positivist
research is critical, as it may not address issues of power and other structural
theory is examined in more depth in a later section of this chapter.
Discussion has turned to the use of narrative analysis as a
potential
alternative to positivist policy analysis, if not a
method to
issues. Cricical
complementary
positivist policy analysis (Feilzer, 2010; Jones & McBeth, 2010). Some seek to
devise
Source: Kondro, W. (2002, May 11). Poverty is main predictor of heart disease, says Canadian
arc
as
such
a
an
report. The Lancet, p. 1679.
theory-driven approach to narrative that satisfies Sabatier's criteria that
approach is both empirical and falsifiable (Jones & McBeth, 2010).
STRUCTURAL FUNCTIONALISM
Positivist
Policy Analysis and Alternative Frameworks
In
practice, many inquiries that
are
grounded in structural-functionalist
apply positivist notions of knowledge and methodology.
Structural functionalism is a social
theory developed by early sociologists after
positivism (Babble & Benaquisto, 2010). Like
positivism, it can also support
the medical
approach to health. This theory views society as an organism,
of
approaches tend
Public policy analysts have
long debated the value of alternative analytic framewoks
examining and improving public policy decisions. During the
19905, a debate on
positivism and post-positivism (i.e., narrative deconstructio
examined the merits of each
approach (Jones & McBeth, 2010). Weimer (1970
and
paradigms
for
to
a
ystem
parts, all of which serve a function
together
for the overall effectiveness
Hcalth Policy
52
in
Canada
ot checks and balance
a
and efficiency of society. It views society as system
nces.
Structural functionalism is, at its core, a consensus theory. It is therefore
theory that
sees
built upon order, interrelation, and balance
maintain the smooth functioning of the whole.
society as
ong
tacit agreements between groune
society, focuses on social order based on
and organizations, and views social change as occurring in a slow and orderly
fashion. Functionalists acknowledge that change is sometimes necessaryto
social
dystunctions (the opposite
functions), but that it must
adapt without rapid disorder.
of
occur
that people and institutions can
To sum up, structural functionalism makes specific assumptions about
slowly so
hermeneutics, is an approach that highlights how individuals understand
or
h
and others through
celves
amono
parts as a means to
Structural functionalism views shared norms and values as the basis of
correct
Ways of Knowing
shared systems of
meaning (Wilson, 1983a).
Interpretivism begins from the premise that people create meaning to make
of their actions and the conditions in which they live and work. Meaning
sense
anifests itself through shared categories that help make sense of interpersonal
(Park,
social institutions
relationships and
1993).
include symbolic interactionism,
The intellectual partners in this paradigm
and
erhnography, participant
grounded theory, among others
Guba, 2011). This perspective clearly
of positivism, but may not explicitly
observation,
&
(Lincoln, 1994; Lincoln, Lynham,
beyond
moves
many
issues of
address
limitations
unequal poOwer
relations
created
by societal
institutions
of the
Allocation and integration are two fundamental processes necessary
One
and social
interesting aspects
and economic, political,
that all views are considered equally valid. Individuals
is
of this approach
occurs are accepted without
understandings of how and why something
clear issues of injustice and
when
there
are
be a problem
critique. This may
or understood by the individual being
be
not
perceived
inequality that may
considered. Thus, interpretive approaches
studied or the policy issue being
contexts that help explain individual
to removing important
lead
also
can
for a state of equilibrium within a system.
understandings and experiences.
society:
held together by co-operation and orderliness.
best when they function smoothly as organisms, with
work
Societies
all parts working toward the "natural or smooth working of the
Societies
are
system.
Each part interrelates
capable
individuals
to create
must
efficiency
be motivated
roles/positions.
to
and
harmony;
ill the
most
the
most
important
boundaries
Systems tend toward self-maintenance involving control of
and relationships of parts to the whole, control of the environment,
and control of tendencies to change the system from within.
of health studies that examine the
interpretive approach is typical
with various health conditions. The focus is on
experience of an individual
the condition from he standpoint of the
describing and understanding
into the lived experiences
individual. Such studies provide important insights
The
When applied to health and health policy, structural functionalism would
have limited use. It would view health issues as "fhixable" through medical
intervention, as cach part of society would be successfully fulfiling a function.
Effective change, in other words, is difficult to explain with this model.
system. The results
their families in
and
other individuals who have similar experiences
the
in
their
body of knowledge
studies also have
health
of individuals and their interactions with the
help
providing support. Such
may
decisions (Raphael et al., 2004).
the earlier discussion, the socio-environmental approach
because it emphasizes
to health presented earlier is related to interpretivism
socio-environmental
approach also
the lived experiences of individuals. The
him or her to hnd
in activities that enable
the individual to
Linking again
dructures, such
nse
Interpretivism emerged from a critique of positivism (Bryman, Bell, && Teevan,
2012). As such, it offers an alternative to
positivist social science. Interpretivists
place
various
ccOurages
meaning in his
INTERPRETIVISM
care
and support. lt
medical conditions and their implications for coping
studies are clearly subordinate
is a fair conclusion, however, that these kinds of
and rarely inform health policy
to positivist-oriented health sciences studies
on
Limitations of Structural Functionalism
forces.
of
od
to
engage
or
as
her life. Social
community
connectedness.
be a
context
important as communiy
to promotc
organizations, help
becomes
a
centres or
individuals
Clearly understanding
valuable addition when carrying
policy studies that aim
to
maintain
out
health
and promote healtn.
lived
experiences
sciences and healtn
Health Policy
54
in
Canada
55
Ways of Knowing
Symbolic Interactionism
(ways of talking about and understanding issues of concern) (Torgerson,
As noted,
Symbolic
symbolic
interactionism dovetails
interactionism is based
on
interpretive annro.
with the
qualitative
research,
not
ch
quantitati.
ive
experiene
figures
and subjective analysis. Perception is everything. Meaning derives from cial
and tables, and it is primarily
concerned with
individual
interaction. In other words, it is possible to understand a person's actions i in
relation
to
other (surrounding) people. Body
language
is
a
perfect example.
1996). Critical theory, also termed critical realism, differentiates berween the
world and peoples actual experience of it, and also berween the real, the actual,
and the empirical (Sayers, 2000; see Box 2.6).
Box 2.6:
Key
Features of Critical Realism
Critical realism distinguishes not only between the world and our experience
Limitations of Interpretive Approaches
is its treatment of all perspectives
The primary weakness of this way of knowing
account the impact of social relations.
into
take
to
fails
It
as equally valid.
social and other inequalities and
particular, the approach does not consider
of individuals concerning
how these shape the experiences and understandings
Few of these kinds
care
health
the
of
system.
health issues and their experience
of
a health isue to the
immediate
the
link
experience
of analyses explicitly
on individual health outcomes and the experience
influence of
larger
understanding
and powers. Whether they be physical, like minerals, or social,
like bureaucracies, they have certain structures and causal powers, that is,
or
capacities to behave in particular ways, and causal liabilities passive powers,
that is specific susceptibilities to certain kinds of change.
structures
systems
of the health care system.
In addition, the interpretive
consider how differences
even come to be considered a
approach fails
to
in power and infuence often define what may
do some health and health care issues arise
health issue.
Why
at
decides what is a health issue and how it is ultimately defined?
Critical approaches include critical realism, critique and deconstruction, and
political economy (Torgerson, 1996). These perspectives vary in the degree to
which they examine the interplay berween power and public policy
Unlike the other approaches, critical theory considers the "haves" and
of society. It also considers power relationships and social inequality
"have-nots
It frequently focuses on the socio-economic context in which institutions are
An alternative approach is critical theory. This perspective is concerned wi
and
R.
development
CRITICAL THEORY
the structures and processes
Sayers, A. (2000). Realism and social science. London: Sage Publications: Bhaskar,
(1975). A realist sheoryofscience. Leeds: Leeds Books.
Sources:
certain tims
take
shapes the form that health care institutions
and the kinds of day-to-day aspects of life that individuals experience? Who
while others do not? Who
that are
usually hidden and ignored by positivi
idealists/interpretivists. Critical theory is social theory oriented to
critiquing and transforming society
whole, in contrast to trau
a
which is concerned
primarily with understanding or explaining society
as it is. Critical
refers
to a cluster of
theory
perspectives that challenge the
of both the
bases
igms
positivist/rationalist and
Pai
These approaches inform the
health sciences and health
policy areas by
actors (those involved
in
developing research and policy) within dic
interpretive/hermeneutics
and individuals' lives are lived (Torgerson, 1996). Critical theorists
focus on the nature and distribution of power among social institutions such
shaped
as the state, the economic system, and citizens in their ability to bring about
ward
ional
as
theory,
in
of it, but berween the real, the actual and the empirical, defining these
to "the real" this
refer
When
critical
realists
1975).
a special way (Bhaskar,
is not in order to claim privileged knowledge of it but to note two things.
of whether
First, the real is whatever exists, be it natural or social, regardless
it is an empirical object for us, and whether we happen to have an adequate
of its nature. Secondly, the real is the real of objects, their
cating
c o u r s e s
social and political change.
Critical theory explicitly links forms of
knowledge
to
the existence and
application of various degrees of power as a central organizing concept (ay
1987). By dealing explicicly wich issues of power and domination in the
of
SoCial context of
society, critical theory provides some of these categories
made by
of
constructions
realiey
the
The
considers
understanding.
approach
calth Policy
in
Canada
Ways of Knowing
56
differentially positioned
take.
In its
ors as resulting from the form that their
domination, it f
issues
power and dor
actors
concern
focuses
on
the social,
shaped and
The
means
the
analyses of
Interpretivist
by
lives
distribution
of
hermeneutic
or
conventional
relate
to
societal
and
social relations
which these
hermeneutic
categories
ical context in which institution
political.
are
1996).
(Torgerson,
lived
are
economic,
individuals'
Limitations
quently
of
with
relations
social
can
be understood is
mohasis don power and domination, critical perspectives may neglect
meaning may
power and
not
resources
the distribution of
factors in their attempts to highligh inequalities in infuence
to highlight, however, that critical theory can have
ver.
nat aims to democratize policy analysis. Ies proponer
that
agenda
action
social
a
the best opportunity for collaborative policy analysis
important
that
critical
theory provides
it providespolicy
analysts, such as those employed by professional
berween professional
citizen activists (Fischer, 2000, 2003; Hawkesworth, 1988;
thinktanks and
the basic terms of conventional discussion
Torgerson, 1996). It challenges
and systems.
and domination within
the
with issues of power
some of these categoriee
social context of society,
the form
understanding. In
It is important
argue
expose im ortant
that are themselh
institutions
shaped by
By dealing explicitly
emphasis
other
.
lived experience of individuals
describe ssome of thesc relation
analyses can
categories of
their
With
and
d the
resources
of Critical Theory
demands
that author
nd
and
also
inciples. It
insiohe
in this volume,
of critical theory presented
c o n c e r n with power and suggest
the
intorm
enables
and decision
making
be rooted in democratic
the combination of different forms of evidence for
political advocacy.
the critical
its limitations,
approach provides insights about power
health issues, which provides a
in analyses of public policy and
and domination
theories
of
and evaluating
public policy and policy change.
critical lens for framing
relevant for analyzing knowledge issues and how they
This lens may be particularly
to influence health policy in the provincial and
that
from political economy
social order is characterized .
The
be necessary.
societal transformation may
contradictions that reproduce themselye
and social
having inherent political
1987).
social inequalities (Fay,
thereby perpetuating
Despite
deployed by particular groups
are
federal policy arenas in
Canada, and in the international
political arena.
Political Economy Approach
critical theory. It focuses on
under the umbrella of
Political economy falls
c o n t e x t to analyze how objective
economic
and
the broader social, political,
of health-related issues (Coburn, 2006,
conditions help inform a variety
economic
living
considers how political and
economy
2010). For example, political
how the
examines
takes. It also
form the health care system
s t r u c t u r e s shape the
shapes mortality and
and social
distribution of economic, political,
It carries out these analyses independent
resources
a
morbidity rates within population.
issues.
citizens may have of these
of the perceptions that
of political
are different types
there
3,
As will be discussed in chapter
with
concerned
is
which
feminist political economy,
economy, including
and other societal
public policy, political ideology,
how gender
It is beyond dispute
for
and how it shapes opportunities
such as political
critical analytic frameworks
that critical theory, in particular
how the
interacts
with
women.
structures
about societies and
identified important questions
cconomy, has
care system
the form of the health
organization of societies shapes
health of the population.
and
tnc
Table 2.1:
Matching Approaches to
Approach to Health
Health with Research
Paradigms
Social Theory That Endorses
theApproach
Medical Approach
Positivism
objective, rational
individual-based or micro
Behavioural/Lifestyle
Approach
Positivism (structural
functionalism)
objective, rational
individual-based or micro
Socio-environmental1
Interpretive
Approach
-
both individual and
-
subjective
environmentally based
Structural/ Critical Approach
socially based, structural,
macro
Critical (and Political
Economy)
- both objective and subjective
Health Policy in
58
APPLICATION
OF
THESE CONCEPTS TO
DETERMINANTS OF HEALTH
THE
Table 2.2: Various Conceptualizations of the Social Determinants of
Health
an
important healt
of health
An
that living conditions
importa
has been
the
Health Canada
Ottawa
primary determinants of health in
cognitio
as Canada (Marmot & Wilkinson, 2006: Raphael,
2008).
The social determinants of healti field is
primarily about
understanding how living conditions-as indicated by such factorsdescri bing a
income levl, employment security, quality of working
conditions,
are
Charter
s
Peace
conceptualizations
in
SDOH National
Organization'
incomeand social
social gradient
Conference
Aboriginal status
stress
early life
social suPport
shelter
nerworks
education
education
food
employment
carly life
education
social exclusion
employment and
and working
working conditions
conditions
physical
income
work
food securiy
unemployment
health care services
social supPport
housing
environments
of the soc
1986, for example, identif
Stable
social
ecosystem
environments
healthy child
sustainable
"prerequisites for health" (World Health Organization, 1986). For t
frst time, health was conceptualized as a resource for living rather than simp
the absence of disease. People were identified as change agents who had te
various
World Health
(CIAR)
status
adeq
housing, levels of education, access to nutritious food, and availability
of
and social services, among othersshape health. Informing these
analyses i
ncern with how the organization, production, and
distribution of sori
and economic resources influence health. As a result, various
researchers nd
organizations have developed sets of social dererminants that show m
1arke
similarities, as well as some differences.
Table 2.2 shows four of the dominant
determinants of health. The Ottawa Charter
59
Ways of Knowing
SOCIAL
example of how these concepts help explicate
issues, consider the issue of the social determinants
development in understanding the sources of health
As
Car
anad
development
resources
social justice
health services
addictions
income and its
distribution
power to act on their social environments to improve their conditions ofliving
equity
The Canadian Institute for Advanced Research (CLAR) drew up its ownis
ofhealth determinants, some ofwhich are social determinants ofhealth, whic
culture
food
social safery net
gender
transport
social exclusion
unemployment and
Health Canada has largely adopted. While on the surface these determina
have similarities with the World Health Organization's "prerequisites ofhealt
some argue that this list of health determinants represents a "re-medicalizadir
of health
promotion" (Labonte, 1996),
as some
of its
terms,
such
as
phystz
and social environments, derive from an epidemiological (that is, posiavi
approach to health. In addition, there is frequently a refocusing on biomedic
FISk factors and a
neglect of issues concerned with the organization orso
and the
unequal distribution of economic, political, and social
(Raphael& Bryant, 2002).
resou
It also recognizes the
rates
infant mortality, morbidity, and mortalicysocid
importa
of available resources and various
as
determinants of health, but it betrays a tendency to apply a concern
C and observable, typical of posicivist notions, at the co
1.
World Health
2.
who.d
Health Canada.
and Irogra
3.
4.
Organization.(1986).
(1998).
Taking action
Ortawa
on
Chaner for
population
health
healsh: A
Branch staf. Ortawa: Health Canada.
promorion.
Retrievad from
posirion paper for Health
www.
Promozion
Wilkinson, RG., & Marmor, M. (2003). Social derernninans
of health: Tre solid fas. Copenhagen:
World Health
Organization European Ofice*.
Raphael, D. (2004). Social determinants of healsh: Canadian perspectits. Toronto: Canadian
Scholars Press.
healt
neAR population health approach considers population-based
status
indicators such
employment security
ith the
sidering
Droader societal issues
and the
concerned with the
unequal distribution
political and economic systems.
he CIAR
approach frequently employs
O1omedical
and
epidemiological
statistical tables
of resources
of traditional
indicators. One such example
is
provided
Health Policy
60
in
Canada
by Labonte (1997), in which a CIAR publication argues for promotino
slight shifts in the overall distribution of serum cholesterol" to infuenco
CVD (cardiovascular diseasc) rate (Labonte, 1997). They say little,
however
about the forces that shape these distributions and the reason for
inequalitic.
in health
outcomes
among different groups. Trevor Hancock
discusses
the CIAR has
early 1990s. He attributes its dominance to its
consistency with growing neoliberalism in advanced capitalist economies
ies
such as Canada and the United States, among others (Hancock, 2011).
He
notes that while population health clearly identifies the social
determinants
of health, it offers litcde on how to address them. It was therefore deemed
more acceptable to governments determined to reduce public
spending, and
reluctant to address the social determinants. Focusing on social determinants
would require addressing the underlying assumptions about the organization
how the population health
health discussion since the
approach typified by
dominated
its
61
Ways of Knowing
on biomedical and behavioural/lifestyle factors, most of these
to consider how the distribution of economic, political,
the form that health care services take and the healh
healch
shapes
Isocial
also emphasize individual responsibility for
These paradigr
itizens.
of
articulate how political power and public policy
fail to
h e a l t h and
ation. Arguably, the medical and lifestyle/behavioural
a populatio
Byparadigms fail
r e s o u r c e s
and
influenc
status
the
health of
making explicit the nature of societal structures
acceptance of society as it is.
cio-environmenta and structural/critical
the socio
approaches
The political economy approach especially
basis for societal change.
of resources and power infuence
how unequal distributions
approaches
t o health,
by
lead
dtheir infuence,
In
an
contrast,
dea
prov
not
to
making and
calls for the
health. These analyses
fhealth care services
suggest
redistribution
that
improved
of such power in
health
the service of
in the form
policy-both
and in the soCial determinants of health-requires
that address inequalities
and
provide
of society (Hancock, 2011). This is in stark contrast to health promotion,
approaches
which challenged the existence of social and health inequalities and called for
social, political, and economic change.
CRITICAL THINKING QUESTIONS
means
policy
for their remediation.
Social science research shows these indicators do not occur in a vacuum.
They
are
inffuenced
by
he broader economic,
policical,
and social
contexts
within which people live. These health indicators-and the living conditions
that spawn them-are amenable
to
public policy action.
In this book, the opportunities provided by the political economy
takes in Canada.
It is assumed that economic, political, and social forces shape the parameters
While
within which health policy is defined and health policy action is taken.
role to play in
each health and epistemological framework has an important
health-related
this exercise, the organization and delivery of health care and
approach are taken to understand the forms that health policy
public policies can
best be understood within
a
political economy framewok.
the
chapter
means
views
and
approaches to understanding health
world
Differing paradigms represent differing
has examined different
of
influencing
concerning the
it.
nature
of health and define the
policy action. These approaches
"appropriate"
themselves
realms
intormed
different ways of knowing. Such epistemological analyses make explicit the
for health
care
2
Which of the approaches to health is consistent with your own view of
what health is and how it can be maintained? What approach do the
media present in reports on health and health care issues?
What
approach underlies Canadian health
epistemological
policy? What
aspects of health do policy-makers emphasize?
3. How do the epistemology approaches of public policy-malkers influence
their receptivity to diverse approaches to health policy issues?
4. Which health approach provides an opportunity for marginalized
populations to influence health policy?
5. How can shifts in health policy occur? Do we need a shift in health policy?
FURTHER READINGSS
CONCLUSIONS
This
1,
are
assumptions about knowledge and how it is created.
Brunner, E., &t Marmot, M. (2006). Social
organization, stress, and health. In
Marmot & R.G. Wilkinson
(Eds.), Social determinants of health (2nd ed.)
M.
P.6-30). Oxford: Oxford University
Press.
his chapter is one of a collection that examines different aspects of the
al determinants of health. While there is an
on
t h e s e all
emphasis
highlight the infuence of social structures
on
quantitatve
health
outcone
Chapter 3
THEORIES OF PUBLIC POLICY
INTRODUCTION: THE CONTRIBUTION
OF PUBLIC POLICY THEORY TOO
UNDERSTANDING HEALTH POLICY
Health policy is a subset
is
a
course
identified
of public policy. As defined in chapter 1, public policy
of action chosen
as a
public
issue
by government to address what has come to be
(Pal, 2006). The political science literature provides
wide range of theories of public policy.
Understanding the assumptions of
these theories and how they are hypothesized to influence the
a
and
development
implementation of public policy is important for understanding a range
of health policy issues.
A theory is a framework for understanding and explaining how a set of
facts
or
phenomena comes to be. It consists of a
set
of statements
or
principles
developed to explain these facts or phenomena (Walt, 1994). Public policy
theories are devised to help explain the nature of decision
in the
making
public
policy process (Brooks & Miljan, 2003). Avariety of such theories exist. Each
thcory ernphasizes different features of the public policy process in an attempr
Cxplain how governments make decisions and develop public policy. They
can also help identify opportunities to infuence the public policy process
to
bring about desired policy change.
nese theories have different approaches to understanding the infiuence of
a n d how it is exercised in the public policy process (Brooks & Miljan,
inform
O t Surprisingly, each theory has a particular set of values that
Each is also informed by a general model ofsociery and how
approaches.
sOciety is considered to function.
67
Health Policy in
OF DIFFERENT
DEFINING
THE
CHARACTERISTICS
Canadh
view
public policy
or
may
take a
proccsS.
predomianty
be
thcorics can
In addition,
contict models
meso
macro-,
ofpublic policy,
as
micro.
dice.
distinguished a
noted in
forces
shape
economic, and social
infiuence
have
cqual
not all
chapter
nor do
on
the
public policy
r
groups
nmodels consider the unequal distribution of.
In contrast. critical
a society. As their desior
and political power in
economic resources
they consider that
suggests,
they critique
government
and
of
unseen structures
concerned with the
incqualiry and povertry.
ignation
public policy decisions. Th.
society
and how
are
these can lead
of
They also consider the role political ideology and d.
The ultimate goal of such modele
market in shaping public policy
policy change
outcomes.
and social and
political
transformation.
broad
Macro-view theories consider
issues
of the general shape of politird
in these political systems. In relation
Ation
and how power is exercised
that health policy consists of two types
been
has
it
argued
health
systems
to
policy,
public policy.
organization and deliveny
of
second is concerned with the development and
The
services.
care
of health
health-related public policies.
implementation of various
The first is concerned with the
be concerned with whether heath
may
Regarding the first type, health policy
financed-that is, provided as entitlements
or privately
are
services
care
publicly
made available as commodities to be bought
through the rights of citizenship or
the
are involved in providing
and sold on the open marker. When governments
of health care services to the population,
financing and direction for the delivery
and managed. This reflects the polis,
the system is said to be publicly financed
is that health
a
defined in chapter 1. The value that underlies public approach
underlies a private
the population. The value that
of
commodification (or selling)
that of free enterprise and the
risk should be shared
across
approach is
goods and services,
not
involved in
including health care. When government-oris
services, it
financing and delivering health care
private system. This is consistent
economic
to
understand how economic,
said
political, and sOC
th infuence and reflect the predominant values within a sociecy
-and have less responsive socie
institutions-may favour
with such
nes to the provision of goods and services. In both
approaches
these systems and related public policies take
aclerstanding the form
macro-level forces.
these
of
market-oriented
cases,
understanding
requires
analyses
theories focus on the inHuence of advisory boards and
ministries, and other "middlegovernments, government
vithin
departments
Middle-level institutions
blic
1998).
policy (Signal,
i n s t i t u t i o n s upon
level"
ernments charged with particular responsibilities
within
zanizations
c a n be
that, while established by governments, operate at arm's
Meso-view
enendent agencies
both types of agencies are still accountable to government
length. Ultimately,
and
public recommendations. These kinds of organizations
fortheir decisions
recommendations of both types of health policy: health care-related
mav make
1he kinds
changes recommended may be
and health-related public policy.
of
profound or incremental.
concerned with administrative routine and the
Micro-view theories are
that shapes policymaking. These concerns
day-to-day government apparatus
of public policy, but the focus is primarily on
minor
tinkering
include
of government operations, including allocating
monitoring the operation
and revising guidelines for practice. Table
operations,
monitoring
spending.
in these wo
3.1 provides some examples of each type of policymaking activity
may
health policy spheres.
Three prominent theories of public policy with value for understanding the
definition, development, and implementation of health policy are pluralism,
new institutionalism, and political economy. These theories provide a lens
through which the features of a health care system and health-related public
policy come about and how they can be changed. Each theory has particular
a55umptions about the nature of society and how public policy is made. In
addition, each theory tends to focus on a specific aspect of the public policy
development process as it attempts to explain public policy outcomes.
the state
tosuch
with a market model ofsociety. Analysis o thes
theories. In
is the focus of macro-level
profound differences in health policy
analyses, it is essential
policy is that of calth-related public policy.
with promoting-cquity andhhuman rights usually create policies
security. Societies that have rather less concern
and
hat assure
.
and
69
valuc-and
Socicties
concerned
consensus
Policy
value-and have
have eco
cconomic, political, and social structures
1
tend to be concernod
bcing eithcr
Walt. 1994). Consensus thheorics
the
1998:
(Signal.
and the various
activities of public policy-makers
ups in
technical. day-to-day
area. They do not cCOni
a
policy
in
specihc
are involved
he
ivil sociery that
that
public policy decisione
political,
lublic
that
of public policy
of the
of
The second type of hcalt
TYPES
OF THEORIES
Theories
heories
PLURALISM
ralism,
or
pluralist
ortant
interest group
theory, identifies interest groups
unit of analysis (Latham,
1952;
Signal,
as the
1998; Walt, 1994;
Icalth Policy in
70
Canada
Table 3.1: Examples of Health Policy Issues at Differing Levels of
Analysis
Health
care
policy |
Macro-Level
Meso-Level
Creation of
Crcating a
public-private
partnerships
Telehealth line
Micro-Level
Increasing
funding to
community
health centres
Changing
Health-related
Creation of
public policy
national day care
eligibility
program
requirements for
Increasing
social assistance
housing subsidy
amounts for
tenants
Dahl, 1961). These groups vie for power and access to the state to achievethe
goals and objectives. This viewpoint is consistent with the idea that demoCratic
societies are generally organized in the interests of the citizenry, and thar
citizens have agency to intluence governmental directions. Policy emerges fromm
competition among these different groups in developing and advancing ideas,
Since pluralism considers that all groups have equal opportunity to
infuence the policy change process, the resulting policy output reflects a
rational balancing of costs and benefits. Pluralist policy analysis identifies
the different interest groups and how they are organized. It also identifies the
resources and strategies they apply to achieve their objectives. In the end, it
documents the
nature
and
success
of their attempts
to
influence the
policy change procesS.
Pluralism and the Liberal
public
Conception of Society
Pluralisn is consistent with a liberal
conception
are considered to
in
participate numerous ways in
ofsociery in which allcitizens
the political process (Walt
1994). The state is considered to consist of a neutral set of institutions that
mediate diverse social and economic interests. Pluralist theory developed
alongsidetheories ofWestern democracy, specifically later theories of democruc
that emphasize the
importance of regular elections as part of the demo
hat
process (Ham & Hill, 1984). Schumpeter (1947) defines
democracy
nstitutional arrangement for arriving at political decisions in which in
individuas
acquire
the power to
decide
by means of a competitive struggle tor
ue
e
Theories of Public Policy
71
Box 3.1: The Pluralist View
1
Basic political rights to vote and free speech safeguard political equality
and individualism. Citizens have access to government through regular
competitive elections, trying to intuence government through advocacy
for particular policy changes and other activities.
2.
Citizens gain power and influence by joining organizations and other
groups to participate in the political process. Citizen engagement provides
a means to challenge government decisions and influence public policy.
3.
The State in a pluralist society is defined as a complex of institutions that
mediates diverse social and economic interests. The State is neutral and
does not align itself with any one class or group, nor does it privilege
particular interests over others.
4.
The State is described as a "plurality" of elites. In other words, no single
elite dominates at all times.
Source: Smith, B. (1977). Policymaking in Brirish government. London: Martin Robertson. Cited in
Walt, G. (1994). Health policx An introduction to process andpower (p. 30). London: Zed Books.
believed
compete to
influence public policy decisions. Thus, pluralism was based on key features
vote (p. 269).
In democracies, interest groups
are
to
that characterize liberal democracy: political rights, citizens' access to political
power, and the responsiveness of the politicalsystem to provide rational public
policy outcomes (Smith, 1977).
For example, Easton's model of the political system shows the different
inputs into the
political
system, with government institutions
at
the
centre.
t presents the government as neutral and therefore receptive to all interests
in society, including the business community, market forces,
and
civil society
organizations such as social movements, unions, and other organizations.
Kingdon's (2003) agenda-setting model also reflects pluralist principles.
s
model depicts the public policy development process as comprisingthree
rcams: problem identification, policy, and political. Each stream is governed
by its own set of rules. How these streams conyerge to generate windows or
stream
PPOrtunity shape policy change outcomes. The problem identihcation
The political
CTe government considers which problems require action.
infuence which
1 the sphere in which political ideology and beliefs
Healrh Policy in
72
Canada
Figure 3.1: Easton's Model of the Political System
Inputs
Outputs
Demands
Support
Resourccs
Institutions of
Goods and
Government
Services
Soure Easton. D. (1965). Afurmework for political analysis. Englewood Clifs, NJ: Prentice-Hlal.
issues and indeed which
public policy proposals
will
gain acceptance by
government (Kingdon, 2003). This stream comprises the dynamics that occur
independently of the other two streams, such as changes in public opinion or
global events like the 2008 economic collapse.
Kingdon conceived the model in the American political context, but
it can be applied to case studies of Canadian public policy. Kingdon streses
that the orientation of a government and its receptivity to addressing an issue
fundamentally influence the movement of an issue onto the public policy agenda.
Figure 3.2: Kingdon's Policy Stream Convergence
Problems
Policy
Proposals
Window
Poliics
Sourte: (ofman,
J.
(2007
Spring). Fvaluation-based theories
Researnh Project. The lvaluation Exchange, XIlI(1), 6-7.
of the
policy
proces. Harvuara
tun
1
Theories of Public Policy
Limitations of Pluralism
or
pluralism fails to consider the role that political power
in the policymaking process (Signal, 1998; Walt,
political ideology plays
these
seems to
Critics argue that
Pluralism
1994; Howlett, Ramesh, & Perl, 2009).
the political process as essentially
concepts, viewing
free. It presents governments
as
explain away
consensual and confiict-
neutral arbiters of diverse interests considercd
infuence the political system. Pluralism does
be equal in their capacity to
social
relations and the existence ofeconomic, political, and
not consider power
structural and societal factors that inffuence
inequalities. It says little about
how it is exercised.
political power and
how governing parties can
Studies of policy change have demonstrated
at
are consistent with their own perspectives
privilege particular interests that
interests (Rochon && Mazmanian, 1993). In
the expense of other groups and
shut out groups whose perspectives
other words, governments can deliberately
Such decisions are ideologically driven.
and solutions differ from their own.
that run in
Governments operate under the control of political parties
Political parties always have a
to
competitive elections on public policy platforms.
their ideological commitments explicit in
political ideology, but may not make
their electoral platforms. These platforms promise to address issues in particular
their selection of priorities and issues, and
ways, but political ideology guides
the types of public policies they enact to address issues they define as important
and requiring public policy action.
dominant
has remained the
Yet, in spite of these limitations, pluralism
to
politics
understanding and approach of advocacy groups trying influence
America.
As a
North
in
and public policy in Western nations, particularly
consensus approach to politics and governance, its avoidance of political
conflict and
neglect
of social
cleavages
makes it
an
attractive
approach
for
advocacy groups trying to change public policies.
for
example,
years-with rather little effect-to
or
particular policy solutions to address poverty
groups will work for
convince government to enact
poor health outcomes. Since these groups have no other way of understanding
the
policy development and change
process,
they
are
limited
to
activities of
infuence governments to change
policy. Ihis may mean advocating for changes to the health care system
aavocating. educating, and attempting
to
such
outcomes,
rather than considering other potential sources of poor health
strive to draw in
spoverty. One way of thinking about this is that groups
than recognizing that
vcrhment by making it "part of the solution," rather
Overnments and their policies may actually be the problem. In the end
Health Policy in Canada
4
pluralism's consensual approach
to
public policy change disguiscs the
with the government
of groups differences
of the
public policy
outcomes
and
may stymie the
soure.
s
developmen.
nt
they seek.
about the limitations of
Much has been written
pluralism. Some
critie.
consider pluralism to offer a simplistic presentation of how the public poli.y
Indeed, McLennan's insights are
works (Howlett et al., 2009).
apt
the
without
works
sense
standard
that
getting
the
"It is impossible to read
process
resources, information and the means of political communication are openly
available to all citizens, that groups form an array of equivalent power centres
in sociery, and that all legitimate voices can and will be heard (McLennan
cited in Howlett
et
al., 2009, pp. 38-39).
Pluralism has little to say about health or income inequalities, for
example,
or
how
they come
about
(Bryant, 2015). Rising
income
inequality
in the United States prompted Dahl and Lindblom (1976), leading pluralist
to explain this issue. This
theorists, to reconsider pluralism and its capacity
1983). This new
led to the development of neo- or post-pluralism (Manley,
school of pluralism inserted influence and power and seemed to permeate
seemed to
pluralist theory with left-leaning politics. In short, neo-pluralism
in
redefine pluralism to consider the unequal distribution of political power
conjunction with the traditional pluralist emphasis on competition among
interest groups in the political process (McFarland, 2007).
As suggested in chapter 1, the pluralist dominance may reflect a preference,
particularly in North American politics, to depoliticize issues and to emphasize
formulations.
individualized approaches to health care and health-related policy
issues
This would explain the preoccupation with health care and the neglect of
that lead to unequal health outcomes.
In the UK and western Europe, policymaking and politics tend to be less
pluralist and more conflict-oriented. This can at times contribute to soCial
and
deavages along racial or income lines. It recognizes, however, that health care
health-related public policy are heavily politicized and require public solutions
ot
While governments responses do not always result in the implementation
progressive policies, governments may be more likely to recognize citizens' neeas
and respond to these needs proactively within such an explanatoryframework
NEW INSTITUTIONALISM
Many political
public policy adopt a consensus-uiriven
political process. One infuential model has been what is termed u
science models of
new
75
Theories of Public Policy
but adds
some pluralist features,
institutionalism. The new
structure the natureof.politics and political
an interest in how institutions
New institutionalism approaches to
debate and the policy change process.
been prominently applied to explain
understanding public policy change have
in Canada (see Tuohy, 1999).
the evolution of the health care system
The focus of the new institutionalism is howsocietalinstitutionsinfluence
1998;
and structure public policymaking and policy change.outcomes (Signal,
institutions structure
Thelen & Steinmo, 1992; Hall & Taylor, 1996). These
the
and manage the politics associated with policy change by determining
conditions and nature of political discourse (March &t Olsen, 1984; Coleman
What
& Skogstad, 1990). That is, institutions define the terms of engagement:
institutionalism
has
are the appropriate public policy domains that can serve as targets of political
action? The new institutionalism is seen as a reaction to the behavioural
approaches that dominated during the 1960s and 1970s (Hall & Taylor, 1996).
In particular, institutionalists identified a lack of theory to explain the manner
by which institutions can toster or impede policy change.
The new institutionalism consists of three frequently integrated theoretical
approaches: (1) historical institutionalism, which traces how the past shapes
the future; (2) rational choice institutionalism, which highlights the economic
position of political
actors;
and (3)
sociological
institutionalism, which
emphasizes culture and norms as determining influences (Hall & Taylor, 1996;
Fischer, 2003). What they all share is a belief that institutions are primary.in
shaping orstructuring the value and policy preferences of those working in
&
the public policy realm (Coleman & Skogstad, 1990; March Olsen, 1984).
Defining Political Institutions
Political institutions arestateand governmentalstructureschat developover time
and persist
in their effects. These institutions can be formal rules of operation,
organizational structures, and standard operating proceduresjas exemplihed by
the rules and regulations established by government institutions for obtaining
services. The new institutionalism conceives these institutions as independent
forces that promote particular ideologies and restrict the choices available
to
policy-makers.
and
These
political
institutions therefore
"structure political
defhne the terms and nature of_political debate.
Institutionalist
analysis can also examine the activities of advisory boards to government,
government departments, and political institutions such as Parliament in order
to
understand how they infuence the public policy process.
Health Policy in
Canada
understanding
significantly to the undere
in
modern socictiee
political change
ieties. Their
of
conmplexity
contribution is in analyzing the intcraction betwcen political elites
elites, interest
contributed
have
New institutionalists
of social and
the
and
idcas in political and policy
groups' demands, institutional processcs,
nalysis
(Hall&Taylor. 1996: King. 1973, 1974). The focus for historical institution
alists
s both macro-level (higher-level) and meso-lcvel (midle-level) proceses.
analyzing both macro- (i.c.. politics and political parties) and meso-level : By
i.e,
encies and decpartments) processes, they provide analyses of some of the mo
ost
important infuences on the public policy process (Signal, 1998).
Historical Institutionalism: The Development of
Public Health Care
Historical institutionalism provides one theoretical framework for examining
health and health care policy issues.by highlighting howthe instirutions of a
political system structure policy discourse (Tuohy, 1992, 1999). One objective
ofthe framework is to understand the uniqueness of national political outcomes.
Another is to understand how the inequalities that characterize these outcomes
come about (Eckstein & Apter, 1963).
Historical institutionalism identifies conflict among
competing groups tor
scarce resources as key to understanding politics. An important focus is on
political and economic structures may interact with each other and with
Current
situations
while others
are
to
produce
outcomes
demobilized or
where
some
interests
are
privileged
ignored.
For example, Carolyn Tuohy draws on historical institutionalism and
rational choice
approaches to explain health care decision making and varying
policy outcomes in the United Kingdom, Canada, and the United States
(Tuohy, 1999). Tuohy examines the logics of particular decision-making
systems within which actors are considered to respond
rationally to incentiv
and resources available to them. In
other words, political goals and objectivesi
as well as the
strategies to achieve these objectives, result from the incenu
and resources
ives
available
change
in
policy-makers. She argues that the dynamie
decision-making systems must consider the temporal contex That
to
policy change occurs when choices become
available as a result of part
historical contexts. Structure
allows change, but also sets limits to
15,
"ticular
chag
The structural
Categories
dimension relates to the
the balance of influence across key
the case of health
care, the balance across tne State,
of actors: in
17
Theories of Public Policy
the medical profession, and private finance. The institutional dimension
refers to the mix of various instruments of social control-hierarchy, market,
and collegiality. Change in the policy parameters cstablishing the structural
balance and the institutional mix of the health care system requires an
xtraordinary mobilization ofpolitical authority and will. (Tuohy, 1999, p. 7)
Further, she argues that a key feature of the three health care systems and
the
the
political dynamics that shaped them is how they have structured
relationship between the medical profession and the state. These systems are
logics
or
and the constellation of interests that exist at
confluence occurs. Once established, the institutional
shaped by the climate of ideas
the time that such
a
to generate a distinctive
mix and structural balance of these systems intersect
the behavior of participants and the ongoing dynamic of
that
governs
logic
change. (Tuohy, 1999, p. 7)
single-payer system, which
Canadian approach to health care, operates
has become synonymous with the
of an accommodation between the
according to the logic or dynamics
The provincial and territorial
medical profession and the state (Tuohy, 1999).
for a comprehensive range of medical and
governments are the "single payers"
to those living in the
on the basis of need
hospital services that are provided
Services
United Kingdom, the National Health
province or territory. In the
By way of illustration, Tuohy
argues that the
and the British
relationship between the government
which a
An agency relationship is one in
medical profession (Tuohy, 1999).
authority
care services assigns decision-making
prospective recipient of health
have wide
Providers in such relationships
to particular health care providers.
involves
an
discretion
to
agency
decide the
will receive. Mechanisms
nature
of and how much medical
individual
abuse that
potential
put in place to protect against
wide discretion for providers.
were
for national health insurance
are
may stem from allowing
In the United States, although
unsuccesstul,
care an
proposals
the immediate postwar era gave way
to
initiatives such
as
hospital
1999). Tuohy thus
from the federal government (Tuohy,
in each
structural balance established
Onsiders the institutional mix and the
response to
at their particular policy
to understand how each arrived
COnstruction grants
Ountry
the provision of health care services (Tuohy, 1999).
and
roles of government
care systems. luohys
on the
is evident, Tuohy focuses primarily
the health
medical profession in the development of
s
s
on
institutions
seems
to
exclude other important
factors and groups,
Health Policy in
such
as
citizens and the labour
movements,
in these countries
thar
that
Canad
anada
help
bring about a public health care system in Canada and the United Kingdom
As noted. in this analysis, institutions are central to understandin.
outcomes. Some argue that while institutions can be important
analysis
to
explain
of
different aspects of public policy development, in
ality
such an analysis says little about how public policies develop or chano
time (Thelen & Steinmo, 1992). It may be that institutionalism as a
policy
framework minimizes the degree of policy change that is possible (Clema
&
emens
Cook. 1999). It does so by emphasiz1ng that institutions can constrain
and
the
limit opportunities for change because they are enduring, and embodu.
social. political, and economic values of a society. These, in turn, are influenced
by structures and
interests in
a
society over time.
Since they seem to constrain change, institutions may not be a useful
analytic tool for explaining change. There is a need to consider institutione
in relation to other factors that influence public policy outcomes. These may
include various social, political, and economic forces than can be mobilized in
the service of public policy change.
The new institutionalism is considered a middle-level theory about the
evolution of health care systems. Ideas and knowledge are seen as driving policy
responses. The new institutionalism can therefore be understood as a rational
approach to public policy analysis. In contrast to the new institutionalism,
political economy is a
materialist perspective that considers living conditions as
giving rise to ideas for social and policy change (Coburn, 2010).
The Political Economy Critique
Contrast Tuohy's view of the development of the Canadian health care system
with the political economy perspective. The latter sees the creation of the publie
health
the
care
state to
on
victory for the working class, which made demands
erd
provide social security to citizens in the immediate postwar
system
as a
(Teeple, 2000; Armstrong & Armstrong, 2003).
ts
In this analysis, the public health care system, as well as many aspects
when
the welfare state in Canada, came about during the 1960s and 19705, WI
the economy was thriving. Political and economic forces were able to pressu
governments to provide a modicum of economic and social security to tu
citizens
ir
(Armstrong & Armstrong, 2003).
The sceds of these movements were planted at the end of the de
the
World
War, when citizens developed expectations that their efforts dur
79
Theories of Public Policy
war required some responses. It took many years following the war to build
on this momentum, however, and this was especially the case for the public
health care system. Ruling politicians, the media, and the medical profession
of public health care and what they perceived to be a socialist idea.
wary
Nevertheless, the government of Tommy Douglas in Saskatchewan
were
system in 1947, which was
that the federal government decided
well received. It wasn't until the 1960s
national health care system on the successful health care program
to model a
Saskatchewan. How can we explain the role played by economic,
established the first publicly
funded health
care
established in
such
political, and social forces
as
these in the
policy development process?
ECONOMY APPROACH
OVERVIEW OF THE POLITICAL
political economy approach offers the
policy, including health policy,
understanding.howpublic
most useful means of
these concepts to
To provide a means of applying
implemented.
is created and
introduces a variety of
remainder of this chapter
the
health
policy,
the study of
illustrations.
It is the
premise
of this book that the
and
political economy concepts
The political economy approach
to
understanding policy development
with theeconomic. political,
change is explicitly concerned
and
and socialstructures
society (Armstrong,
Coburn,
& Armstrong, 2003;
Armstrong
2001;
economic
Armstrong, & Coburn,
and distribution of
production
the
organizes
Political
that infuence
the distribution
2006). How
society
and social
a
resources
is
of power
essential to
and resources in a
understanding
policy
outcomes.
markets, power, ideas,
at states,
these inquiries by looking
economists carry out
development.
their impact o n policy
and civil society and
discourses,
number of political
economy
2006).
perspectives (Coburn,
contrast
In
is materialist.
perspective
economy
materialist
One important political
of ideas,
on the primacy
and
institutionalist emphasis
the production
to the n e w
organizes
a
consider that how society
institutions.
There
political
are a
economists
aistribution
Oical
of social and
economists use
economic
concepts
explain political
events
resources
such
as
shapes ideas
and
and social
production
the mode of
The
(Grabb, 2002).
and phenomena
and
mode
services are
which societal goods
current
m a n n e r in
the
to
countries, the
Or production refers
other
most
In Canada and
Political economy
produced and distributed.
production.
of
capitalist mode
SOCial formation is the
all aspects of economic
shapes
production
in s o c e y
mode of
that this capitalist
different groups
Class to
OsIders
relations
including
social
life,
polltical, and
among
Health Policy in
80
Groups that
are
especially important include
others (Grabb,
those
that differ
differ
2002).
Canada
byh. social
clas,
gender, and race, among
also concerned with the complex
of
Feminist political economy is
institution
and social relations that operate through the political and economic system
shape ideological and cultural systems (Drache & Clement, 1985). Fem
Dolitical economy focuses on gender and how it structures women's acce.
s to
health care services and their opportunities tor good health as compared to m
men
(Armstrong & Armstrong, 2010). There is also interest in the power dynawd
amic
that shapes these relations and the conditions of lite for men and women such
that men appear to have more-and better-opportunities than women,
Box 3.2: Focus of a Feminist Political Economy
Feminist political economy considers how the political, economic, and social
organization of health
structures
opportunities for health for women. This
focus is concerned with the role of political ideology in shaping health policy
indeed all public policies, with an attendant analysis of implications for
women and other vulnerable populations. Thus, it is assumed that gender,
race, and other social attributes such as class can increase vulnerabiliry
is the increased likelihood of experiencing social and
Especially important
economic marginalization.
Political Economy as Critical Social Science Applied to
Public Policy
Materialist and other political economy perspectives represent a critical
SCIence perspective (Coburn, 2004, 2000, 2001; Armstrong et al., Z00
nbodies
Political economy focuses on issues of power. As critical social theory, it emb
the
a
transformative component. This means that people are considered to na
power and the ability to change their environment, such as improving
conditions and health in the
community
in which
they
living
addition,
live. In
important outcome component of a political economy analysis is how
an
power
The
shapes policy change, which then infuences the health of
populating
context in which events such as the development of public policies O
coniict
among groups in society
erging
Relation
occur
is
considered important.
Iheories of Public Policy
81
and power are considered to shape this context and the social, political, and
cconomic institutions that develop in a society.
The Role of the State: Accumulation and Legitimation
Central to the political economy perspective is recognition of the role of the
state. O'Connor (1973) argues that the capitalist state plays critical roles
of accumulation and legitimation. Accumulation refers to state provision
of the conditions that enable building private (profics States help foster
these conditions by providing infrastructure such as-róads, highways, and
communication services, and an educated workforce. States also ensure social
cohesion and mediate confiict among social classes by providing a justice
system
and services. Legitimation
to use
force in order
to ensure
refers
to
the state's
socially sanctioned right
social order and cohesion. Accumulation and
legitimation are contradictory roles that require the state to vary its support
berween business and
labour
in
order to
maintain social cohesion and reduce
the possibility of class conflict.
for
by the(1970s, states were paying
at the same
of the costs of accumulation than they had in the past, yet
interests.
time allowed for the collection and control of profits by private
O'Connor argues that
more
OConnor attributes the oil crisis that developed in the 1970s to the private
interests (O'Connor, 1973;
appropriation of state power to protect private
the
Within a political economy perspective,
&
2003).
Armstrong,
Armstrong
adverse impacts
and accumulation have particularly
processes
of legitimation
On women
and racial minorities in
the formal economy. They
market"
Surplus populations outside the
(Armstrong
p. 8, O'Connor, 1973).
others
Armstrong and Armstrong and
impacts these
PcClal
Dcar
the
*Cxample,
Pproaches
des.
to
larger
processes
burden
changes
health
of
O'Connor
neglects
for
the
women,
role that resulted in increasing market
witnin
carry out
primary caregivers
rmally
normaily
health care responsibilities
families
such as nurses, in their
women as
professionals,
Oy trained health care
O'Connor's theory requires
Crmstrongs argue that
a
third role tor
tne
1nls i in the
legitimation:
for publicy
what is provided
in these
a critical role "in structuring
does the work
who
in determining
privarely in households,
c n addition to accumulation and
S
Armstrong, 2010,
on
have affected
Women frequently
that
large
households, particularly
& Armstrong, 2003).
caregiving (Armstrong
have
in the state's
care
argue
&
foster
distribution.
Health Policy
in
Canada
2
&
Armstrong,
2010,
donc" (Armnstrong
how it is
of the welfare
spheres and
componcnts
arc integral
hcalth
contributeo
ited to the
hcalth care and
from the labour
public
hcal1h
movcment
programs
care
The Impact of
and
in
Political
countrics,
Ideology on
economists
a
stat.
d
ressure
development
citizcns
Western
p.
cxcept
cxcept
the UnitedSta
Health
Policy
is the influence of
the asco
to political
particular intcrest
Of
ncolibcralism
as a governing political ideology. Neoliberalism is a Doliti.al
fostering economic prou
growth
are
policies
seen
Specihcally, free enterprise
and innovation (Coburn, 2000).
of
the
the
population
well-being
and the basis for
to cconomic growth
idcology that
as
favours the market
as
the vehicle for
key
advent of neoliberalism to events in the 1970
Political economists trace the
2000; Coburn, 2006). Morever, they
such as the oil crisis in 1973 XTeeple,
reduce the power of labour, and contracting
consider deregulation, efforts to
deliberate attempts to
or accidental, but as
the role of the state as not inevitable
2007).
shift political and economic power (Harvey,
influence of neoliberalism on the organization
In later chapters, the specific
these sections, the focus is
of health care will be examined. In
and
delivery
growing inequalities in health
how neoliberalism has been associated with economies
such as Canada, the
betrween different groups in developed political
health refer to unequal health outcomes that
US, and the UK. Inequalities in
on
are
based
on some
group
characteristic
of individuals.
AND
HEALTH INEQUALITIES, SOCIAL INEQUALITIES,
HEALTH CARE
function of social
1992;
Davidson, & Whitehead,
class or occupational status (Townsend,
focus has been on isues
Mackenbach && Bakker, 2002). In Canada, the primary
established the
vast literature has
A
2007b).
and
income
of
poverty (Raphael,
link berween low income and poverty with poor health status and outconc
2004; Raphael, 2007a).
Choinière,
&
Lessard,
2002;
Raynault,
Auger,
(Phipps,
In
Europe, the focus has been
on
health inequalities
as a
Their belief in markets means that supporters of neoliberalism tenu
accept whatever the market
produces, including social and health inequalites
sonal
These inequalities are seen as somewhat natural and stemming from perso
failure to succeed in the market. They do not usually consider these inequan
s
Theories
of Public Policy
83
The Main Tenets of Neoliberalism
Box 3.3:
that neoliberalism refers to the dominance of
David Coburn considers
He identifies the three main assumptions of
markets and the market model.
neoliberalism and the new right:
in the production and distribution
as
1 . Markets are perceived most efficient
of resources in a society.
2.
Societies are comprised of autonomous individuals (producers and
consumers) who are driven primarily by material or economic gain.
3.
Competition is the primary source of innovation.
Coburn distinguishes between neoliberalism and neoconservatism because
component supportive of
the latter is concerned with a particular social
*
traditional family values and certain religious traditions, among other issues,
and is not only concerned with a laissez-faire economic doctrine. The essence
of neoliberalism is a commitment to the virtues of a market economy.
Moreover, neoliberals tend not to be troubled by inequality, nor do they
consider it as either positive or inevitable. If the market is "the best or most
efficient allocator of goods and resources, neoliberals are inclined to accept
whatever markets bring" (Coburn, 2000, p. 138).
Source: Coburn, D. (2000). Income inequality, social cohesion, and the health status of
popuations: The role of neo-liberalism. Social Science &Medicine, 51(1), 135-146.
to be related to public policies that allow increased skewing of the distribution
Or cconomic resources or to the social exclusion of some groups. Social exclusion
is closely associated with social inequalities. Social exclusion is a process of
marginalization of some groups, such as indigenous populations arnd populatio
of colour, among others, resulting in these groups being denied access to basic
resources, such as suffhcient income and affordable housing. This process is
Strongly infiuenced by a wide range of forces, as illustrated in Figure 3.5.
oburn (2000) considers the relationship berween income inequality and
health within and among nations. He argues that there is a need to consider the
and health' (p. 136) by analyzing the social,
Socal causes ofinequality
PotICal, and economic context within which income and health inequalities
Health Policy
84
Figure
in
Canada
3.3: Social Exclusion in Context
Globalization and Associatcd Structural Changes
National Context: Particularitics of
Economic Policy, Welfare Regimes, Rights of
Citizenship, and Responses to Globalization
Local Context: Particularities
of Place, Population, and Local
Governance
Social Exclusion
Source: Percy-Smith, J. (2000). Introduction: The contours of social exclusion. In J. Percy-Smith (Ed),
Poligy responses to social excdusion: Toward incusion (p. 5). Buckingham: Open University Pre.
emerge. Coburn and others have linked inequalities to the welfare state and
the class origins of different types of welfare state regimes. Such a focus enables
a consideration of the relationships among markets, states, and civil society.
Coburn argues that it also presents a different causal configuration abour
national and international differences in income inequality and in longevity
than are usually acknowledged in the literature.
Neoliberalism has undermined the welfare state, as reflected by Western
governments such as Canada and the United Kingdom, by dismantling social
the
programs that form these welfare states. As noted earlier in this chapter,
formation of the welfare state was intended as a way of sharing risk across tne
population, and as means to redistribute income and access to programs from
higher-income groups to lower-income groups.
Considerable research evidence shows that low-income groups espec
benefit from these programs. Indeed, reduced poverty rates among ditierent
groups, particularly seniors, have been attributed to weltare state program
(Raphael, 2007b). Coburn and others have argued that the weltare st
contributed to social cohesion or solidarity among social classes because
of
class differences. Coburn shows that the basic
cial
neoliberalism are consistent with higher levels of inequality and lowered so
it
mitigated
assumption
cohesion or increased class conflict attributable to accentuated differete
among classes (Coburn, 2000).
Theories
85
of Public Policy
neoliberal policies have led
through cutbacks in public
have shown how
to
Armstrong and Armstrong
undermined health
reforms that have
care
managing health care services (Armstrong &
in
Armstrong 2003). They argue that hospital CEOs particular have adopted
fnancing and
new
approaches
to
with a view to making hospitals more efficient.
management strategies
This approach results in reducing nursing and other hospital staff and providing
Care at the lowest unit cost (Bourgeault, 2006, 2010). This means that hospital
new
staff who tend to be the least skilled in patient care usually end up providing
patient care.
families are trained
of
Some observers describe the deskilling care, whereby
greater
amounts
of
to perform activities usually pertormed by registered nurses, such as inserting
Some
catheters and other health equipment (Armstrong Armstrong, 2003).
nurses as a way of
hospitals trained cleaning staff to do the work of registered
&
reducing the cost of patient care. These processes
have contributed
to a
decline
Box 3.4: Political Economy Analysis: Social Exclusion, Gender,
Race, and Health
A political economy approach can be applied to examine how social
positions
such
as
gender and
race structure
opportunities for health and the
determinants of health such as income, employment, and access to a range
of other resources. Political economy examines how race, gender, and other
factors lead to social exclusion. Social exclusion is defined as both a process and
an outcome, whereby people experience social and economic marginalization
on the basis of gender, race, or another characteristic (Galabuzi, 2006).
Political economists reject the view that the capitalist formation and the
social relations that develop within society are inevitable (Coburn, 2006;
and the social relations that
consider
leeple, 2000). Rather, they
capitalism
trom
the
of
emerge
organization society, such as inequalities
berween
women
and men, White populations and populations of colour, among others, to
be social constructions. That is,
society creates these processes ancd caregories
tO make sense of differences within a population. These processes and
toward
people
tend to reflect the dominant attitudes of a culture
aiegories
Or colour or other marginalized populations. Often, these difterences are
das pathologies or unattractive attributes and
discrimination against various groups.
can
become the basis of
86
in
Health Policy in
patient
that
are
facilities
care,
increased risk of infections
in
hospitals,
and other problem.
ems
of patients' rooms
and othe.
preventable through proper cdeaning
hospitals. These developments have been attributed to the
in
Canada
resourcing of hospitals and the health care system as a whole.
under.
CONCLUSIONS
This
chapter has examined the assumptions of three theories of public
policy that represent the dominant political perspectives in the social science
literature. These theories can be arranged along a continuum trom consensus
models to conflict models of the
policy process. Consensus models tend to
focus on group behaviours in the
political process, whereas conftict theories
are concerned with the
influence of politics and economics on public policy
outcomes. Institutionalist models take amiddle course.
Pluralism has become one of the most influential theories of
and
politics
consists of
in
Western societies such
as
public policy
politics
influence public
Canada. It contends that
"plurality
of interest groups that compete to
policy. No single interest group or policical elite dominates the political process.
a
Pluralism fails to recognize the inequality of access to the political system or
the role of political power. The state is portrayed as a neutral arbitrator of
-
-
interests that contributes to policy decisions arrived at by consensus. Nco-
pluralism attempted to inculcate concerns about income inequality, but it
is unclear to what extent pluralists are concerned with income inequality or
health inequalities.
The new institutionalism focuses on institutions as shaping policy
behaviours and policy change outcomes. It is a structural approach that
considers instirutions to be primary in shaping the preferences and values of
political actors. Institutions "'structure" political reality and define the terms
and nature of political debate. The focus on institutions tends to preclude a
consideration of other forces that may be time-specific and important variables
for understanding policy change outcomes.
Political economy is concerned with the relationship between politics
and economics and how this structures policy change. Material conditions
of societies
are seen as
economy considers
primary in influencing ideas and
political
institutions. Politica
power and the infuence of
political
ideology
on policy change outcomes and health outcomes. It focuses on the broaac
political and economic contexts as being causal factors in infuencing he
outcomes. These theories also represent different levels of analysis.
Theories
of Public Policy
87
nlication of theories retfects difterent perspectives on which factors can help
appl
explain p o l i t i c a l o u t c o m e s .
CRITICAL THINKING QUESTIONS
1.
2.
Which of he public policy theories best explains recent developments
occurring in health policy in Canada?
What are the specific issues of interest of each of the three main public
policy theories?
What kinds of evidence do you think guide current health policymaking
3
in Canada?
4.
How do theories of public policy contribute to our understanding of
health policies and their impact on the health of populations?
5.
What considerations should be brought to bear on health policy discussions
in order to improve health policy decisions?
FURTHER READINGS
Coburn, D. (2000). Income inequality, social cohesion, and the health status
ofpopulations: The
role of neo-liberalism. Social Science
Medicine, 51(1),
135-146.
Coburn is one of the foremost political economy analysts in Canada. In
this, article, Coburn examines the impact of neoliberalism on health policy,
specifically the increase in inequalities
in health in Canada and elsewhere.
Coleman, W., & Skogstad, G. (Eds.). (1990). Policy communities and public
policy in Canada: A structural approach. Toronto: Copp Clark Pittman.
Ihis text is a collection of essays on Canadian public policy examined
Trom a new institutionalist perspective. The essays help to explicate the key
areas of
interest in the
new
Hall, PA., & Taylor,
institutionalism.
R.C.R.
(1996). Political science and
the three
institutionalisms. Political Studies, 44, 936-957.
s
article was among the first to explain the three variants of the new
utionalism and continues to be an important work on this policy approacn.
dennes rational choice, historical, and sociological institutionalism and key
cas of interest of each with reference to American public policy.
Chapter 5
INFLUENCES ON
PUBLIC POLICY
INTRODUCTION
Numerous
influences impinge upon
broad level, political, economic,
the
public policy change
and social
torces
process. At
a
workings
of
related to the
the state or government, and
the attitudes and beliefs
the economic system,
development. Closer to the ground,
of the citizenry shape policy
inftuence the public policy change
interests compete to
groups and
Advocacy organizations play
various
process.
important role in the public policy change
about issues and
to and intorming the public
an
by drawing attention
differ widely in the
solutions. These advocacy organizations
offering policy
their aims. They also vary in their political
they possess to further
realize their health policy goals.
infuence and political clout to
the
to influence policy development depends
Specific groups ability
process
resources
on
area
in which
interests
others.
There may be
they are engaged.
some
policy areas
in which the
entrenched than in
are m o r e
opposing policy options
be shaped by the
influence public policy will also
that support
Ability
to
extent to
-are intormed
change
policy areas-and the potential policy
the day.
of the government of
and consistent with the political ideology
context
for
which specific
Folitical ideology
it
is important because
understanding state receptivity,
dtner than others. Receptivity
as
well
as
provides
resistance,
R
a
to some
for
perspectives
less when
policy options will clearly be
governments ideological
ruling
of
the
components
PO1ICy advocates challenge
tend not to be recepulvc
most governments
short,
In
beliefs.
and
ments"*TGNiwiailwawK
of the day can
government
Any
to
programs.
deliberately
Criticism of their policies and
can be
shut6
0me
interests over
to
others, such that
some
groups
Wolfsfeld, 1993; Bryant,
(Gamson &
health
influences
r the policy change
12
dynamics and
the
of
This
chapter considers some
15).
and various goupa
state itself
policy
process
ada.
the
These infuences include
127
on
Health Policy in anaa
128
frame.
work
civil society.
can be clasci.
that are part of
devclopment
icd
on public policy
thesc influcnces
which
the
Dr
policy
by
that
public
roCcss
this cxamination is
The assumption guiding
are heavily infucnced t
in particular
by
the health policy arena
in general and
2004; Raphacl, 2014).
politics (Rachlis,
Thc
chapter also
cxamines
different
POLITICS
POLICY INFORMED BY
Many theories of publicpolicy present
information
a
rational process in which governments
nt
on an
issue from a
inputs-such as
of various
calculate the benefits and liabilities
receive
variety
of sources
policy options, and then make
issue of the politics of
decision about public policy. The
a carefully reasoned
make explicit that
policymaking challenges this viw. Critical perspectives
is usuallytermed evidence
public policy decisionsfre notbased solely on what
of the political
is
(Bryant, 2015; Raphael, 2014). In reality, policymaking part
characterized as a highly conflictual process that different
process and can be
the corporate, labour, and health and social
groups in civil society, such as
service sectors, among others, vie to intluence, The objective of these activities
is to ensure policy change that protects and enhances their interests.
In the health policy field, these forces include the health professions
(physicians, nurses, psychologists, and others),citizen activists organized
into social movements such as the Canadian Health Coalition and Citizens
for Medicare professional policy analysts, andpolicy institutes such as the
Caledon Institute on Social Policy, the Fraser and C.D. Howe institures, and
the Canadian Centre for Policy Alternatives, among others.
Corporate infuences such as the nursing home and home care industry
the pharmaceutical industry, the medical testing business, and the insurance
industry are well organized and well resourced to carry out advocacy activities.
They lobby governments to develop policy approaches that support their
interests and tend to have close relationships with
government
agencies.
These varied interests themselves are associated with or even embedded in
ideologies that both shape and result from the political, economic, and socia
institutions, the economy, the state or government, and citizen beliefs
and
values that structure society.
these
institutions and ideas shape
Together,
context and form of
public policy discourse and debate. Understanding wi
these groups come from and their
policy goals is critical for understanding
policy change process, as well as those instances when policy does not chang
What are the motivations for such
cases,
advocacy actions? In
many
advo One
groups work for policy goals that clearly benefit their economic interests.
Influences
on
Public
129
Policy
to
of a major pharmaceutical company lobbying governments
that
is
example
manufactured by Merck, against the human
available a vaccine, Gardisil,
make
economic interests
said to cause cervical cancer. Clearly,
papillomavirus, which is
these
substantial proits tor pharmaceutical companies shape
of
form
the
in
initiated a massive immunization campaign
federal
government
activities. The
and mortality of cervical
of evidence showing that incidence
for Gardasil, in spite
Shimmin, & Boscoe,
in Canada (Lippman, Melnychuk,
declined
has
cancer
cervical cancer among
the incidence and mortality from
2007). Indeed, although
overall Canada
for non-indigenous women,
women is higher than
indigenous
cervical cancer prior to the
dramatic reduction in
experienced a
vaccine
development of any
mortaliy from
prevent it.
to
policy changes that
example, advocacy groups
groups seek
advocacy
In other
beliefs. For
with a set of values and
have greater
disadvantaged populations
ensure that socially
cases,
care
and
but
beliets about what the
they pursue
nature
to
may work
access to health
themselves not be
groups may
their values
these efforts in support of
of society should be. Similarly,
work
groups may
housing-related advocacy
homeless
be at risk of becoming
consistent
advocacy
these
services. Members of
socially disadvantaged,
are
to
members
end homelessness, but may
of
not
themselves.
evidence to convince governments
types of
of the issue and
reflect their understanding
that
of the need for policy changes
would be hoped that
addressed. While it
be
could
which
they
evidence,
the means by
based on available
change
for
policy
advocate
these groups would
however, carry
These groups must,
information is not available.
such
frequently
limitations. Not surprisingly
face of these
the
in
even
efforts
decisions in the
on with their
These groups present
Some
suggest that
even
different
governments
frequently
make
policy
evidence (Lindblom, 1959).
the public policymaking
that e n s u r e that
factors
critical
These are all
involves economic
this process also
And
process.
process is an explicitly political
the state and public
beliefs that shape
and
values
the policy
and social forces, such as
a role in
these factors play
All
1994).
health policy process.
policy decision making (Walt,
influence on the
their
in
but vary
development process,
tace
of limited available
NET
as
PROCESS
PUBLIC POLICY
THE
INFLUENCES ON
aiscussed
O
P
in
chapter 3,
a
range
explain different
of m a c r o - ,
inputs
or
meso-,
micro-level
influence
factors that
offers
For example, the pluralistmodel
that considers
perspective of the political ocess
outcomes.
and
how
tneorico
public policy
leyel
generally micro-leva
vie
rival interest greups
a
Health Policy in
130
Canada
to influence the public policy process. Pluralism focuses on how interes
aterest groups
act as inputs into the policymaking system, with the assumption tha
group or set of groups will always dominate policy discussion and action one
Nesw institutionalism is primarily a mneso-levelperspective concerned wi
the role that institutions such as governments, organizations, and agenci
play in shaping policy discourse and debate. lt emphasizes how institutio
ies
ions
and their associated ideas infuence public policy outcomes. Political economy
is primarily a macro-level perspective concerned with how the organizat
ization,
production, and distribution of economic and social resources, political
ideology, and other forces infuence public policy decisions related to the
organization of the health care system. Public policy shapes citizens' living and
working conditions.
A number of models have been developed to identiky and explain the
important influences on policy change. Some theories provide category systems
or typologies to make sense of these various infuences on public policy. For
example, Lcichter (197) identified four groups of factors that influence the
public policy change process:
1. Situational factors
2
3.
4.
Structural factors
Cultural factors
Environmental factors
Leichter's Framework and Its
Implications
In Leichters framewor( situational factors can be sudden.or yviolent events, such
as the 9/11 attack on the US, Hurricane Katrina, the oil price crisis of the 1970s,
or the onset of wars that are associated with policy development and change. Ihese
sometimes enable governments to introducepolicy changes leading.
innovations or other policy responses that might otherwise be unacceptable
to the public or
usually dominant groups (Walt, 1994). For example, duringtne
events can
to
Second WWorld War, the UK government annexed private, voluntary hospitals to
coordinated and national health service (Walt, 1994). This
experiene
during the war showed that it was feasible to provide publicly organized heau
care that ensured all citizens had
access to health care
on the
ensure a
need. That this
basis
services
policy
innovation
was
positively received
helped
to
make n
experience a template for the postwar creation of the National Health Servic
on
Infuences
Public
Policy
131
Rritain and public health care systems in other developed Western countries.
Taking advantage of such governmental upheavals or shocks to introduce policies
hat mav not normally be easily implemented has received increased attention
(see Box 5.1). That these policy innovations may benefitsome groups at
rec
the expense of others is also being
Public
Box 5.1: Shocks and
examined.
Policymaking
Review of The Shock Doctrine: The Rise of Disaster Capitalism,
by Naomi Klein
By Lenora Todaro
Village Voice
In The Shock Doctrine, journalist Klein trains her sharp investigators eye upon
researched alternative
the faws of neoliberal economics. This meticulously
of Chicago
from economist Milton Friedman's "University
Klein's argument into the present. Using
Boys to George W. Bush, brings
like the
the ways that disasters-unnatural ones
stirring reportage, she shows
and Hurricane Katrinaand natural ones like the Asian tsunami
war in
history, ranging
Iraq,
allow governments and multinationals to takeadvantage
of citizenshoek-and
fishing
once was a Sri
implementcorporate-friendly policies: Where
The Shock Doctrine aims its 10-foot-long
village now stands a luxury resort.
of
middle
finger
who've chosen
intellectual
at
the Bush administration and the generations
disaster; the effect is
over people in war and
profits
armor
for the
now-mainstream
neo-cons
to
provide
anticorporatist crowd.
of The shock doctrine,
Todaro, L. (2007, November 27). Review
ource:
Lankan
by Naomi Klein. Village
Voice. Retrieved from www.villagevoice.com
ometimes situational factors
t are unpopular,
such
g e t and debt crisis
the funding of social programs.
used to justify profound
1990s in Canada was
cutbacks
of the early
to
health
care
in both
the provinces and territories
poli
a
other health-related areas. Sometimes what seems like progressive
tederal transfers
L s in
and
as
enable governments to introduce changes
Ihe
ge
to
economic
The 2008
justify not-so-progressive changes.
national governmeh
necessitated stimulus funding, which many
can
pse
be used
to
implemented to support their economies.
Health Policy in Canada
132
Welfare
Marc
Lalonde
example, in 1974, Minister of Health and
A Working Document
published A New Perspective on the Healthof Canadians:
discuss factors such as
(Lalonde, 1974). This was the first federal report to
For
the environment and health-related behaviours as important inHuences on
health. In practice, health professionals seized on lifestyle factors as the
means to promote better health, to the exclusion of environmental factors
More importantlv
& McKay, 2000; Schrecker & Bambra, 2015).
(Legowski
another effect of the report was to justity changes brought about by the
Established Programs Financing Act of 1977. The shift away from health care's
role focusing solely on health allowed the federal government to consider
withdrawing from some of its health care financing commitments (Rachlis,
2004). This act shifted the federal government's contribution to health care
from 50:50 cost-sharing to a block-funding arrangement between the federal
and the provincial and territorial governments.
This change represented a profound shift in health policy. The previous cost
sharing arrangement had helped the provincial and territorial governments accept
medicare at its inception in1961. This 1977 act effectively ended cost-sharing as
the mode of financing health and social services and increased the provincial and
territorial governments financial burden for these services. Lalonde's report
usually seen as a progressive advance in health policy-may have inadvertently
justified the federal government's decision to reduce its transfers to provincial and
territorial health care insurance plans (Rachlis, 2004).
also lead to policy changes (Walt, 1994). A
Structural factors
(2)>
radical change in political leadership can trigger health policy change.
can
Following his election in Venezuela in 1998, for example, socialist Hugo
Chavez initiated health reforms to ensure the provision of health care to
poor and marginalized citizens (Muntaner, Salazar, Benach, & Armada,
2006). The reforms signified a shift away from health care as a commodity
to be bought in the marketplace to the provision of health care as a social
right by means of a public health care system. This shift was especially
important for the marginalized poor living on the periphery of large urban
centres who previously did not have access to health care (see Box 5.2).
As another example of how structural factors can affect the organization
of the health care system, consider the Unitcd States, which has a private
health care system rooted in its free market economic system. Instead of
having a public health care system primarily organized by the state, which
st
is the case in every other aeveiopcd nati0n, the US has numerous private
rance
provide
differing
coverage.
Presidentto
Barack Obama's Patient
Protection
and Affordable health
Care Act
forces citizens
plans that
levels of
atduences
on
lublic
Policy
133
ROx 5.2: Structural Change and Health Policy in Venezuela
Llnan
election
in
1998,
Hugo
Chavez enmbarked
on
health
care
reforms
rhat would ensure the health care provision as a social right particularly to
marginalized populations. Muntaner and colleagues (2006) argue that the
reforms signihed a movement avay from health as a commodity to the
nrovision of health
social
care as a
right.
This social
right would be provided
by means of a public health care system that provided care to all, including
the marginalized poor who lived on the periphery of large urban centres in
the country.
During the 1980s, most Latin American countries had significantly
reduced health and social programs. These deep funding cuts, characteristic of
structural adjustment policies during this period, gradually led to conditions
that fostered neoliberal reforms, the destabilization of the welfare state, and
the erosion of social services such as health care. In Venezuela, the erosion of
welfare instiutions throughout the 1990s fuelled cals for health care reform.
During the election campaign, Chavez campaigned vigorously against further
neoliberal retorm. Once in ofhce, Chavez called for a referendum on a new
"Bolivarian" constitution, prepared by a special constituent assembly. Three
articles in the new constitution contained important implications for health
care reform. First, health was viewed as a fundamental human right that the
state was
obliged
to ensure
(Article 83); second, the
state
had the
duty
to
create and manage a universal, integrated public health system providing
services that were free at point of access and prioritized disease prevention
and health promotion (Article 84); and third, this public health care system
must
the
be publicly financed
state
regulating both
developing a
human
with
through taxes, social security, and oil revenues,
and
the public and private elements of the system
the new system
policy to train professionals for
resource
Article 85).
Jo1n one of these plans. The act also outlaws the practice of underwrlting
applicants for_previous health
ngurance companies screened
conditions (Hall & Lord, 2014)
VIOst
Americans
now
pay additional health
H
L7Otection
have
some
care costs
but many
form of insurance coverage,
their plans.
that are not covered by
Obamacare-aimed
and Affordable Care Act-or
1
to insure
in Canada
Health Policy
134
all
Americans
in 2010
private insurance
(Hall
change how
Medicaid to
to
expands.Medicaid
act does
&
Lord, 2014). The act
hospitals. It
not
physicians
insure those living near the poverty
line, and subsidizes private insurance for
insure those livine
their employer. Under
PEOple who are not poor but have no coverage through But, the act does
not
the act,
private insurers cannot deny health coverage
remunerates
or
create universal coverage or change the structure of the US health care system.
t
requires all Americans
purchase their health insurance from he private
to
health insurance industry or face exorbitant fines.
The US continues to outspend all other countries in health care at
17.7 percent of its GDP the equivalent of USD $8,508 per person per year
(Organisation for Economic Co-operation and Development, 2013). This is
100 percent
approximately 50 percent to
more
than other nations.
Demographic and social factors are also social and structural determinants
that can affect public policy (Leichter, 1979). The extent to which a country
is urbanized affects the structures that are developed to provide health and
other services. The age structure of the population afects the type of health
services that are provided (Walt, 1994). For example, depending on the
perceived
long-term
health of seniors, governments might move to ensure provision of
medicare to include
care and palliative services, such as expanding
a national pharmacare program, as many have urged the federal government
to implement in Canada (Gagnon & Hebert, 2010; Morgan et al., 2015) (see
Box 4.3). These kinds of issues inform current debates about wait times,
especially as hip replacement appears
to
be
an
emerging issue.
Such
surgeries
tend to be more prevalent among the elderly.
Culture affects
The
policy.
political
and cultural environment can
infuence levels of participation and trust in government and the possibility of
1979). In a situation where the populace does not
trust government, their subsequent disengagement from the political system
political change (Leichter,
on
further hinder policy change. Believing that they have no infuence
and more people decide not to vote at election
the political process, more
between elections may make it unlikely that a
time. Lack of interest and delays
will do anything to change public policies.
government
can
It has also been suggested that the dominant religions of a country can
( Walt, 1994). For example, some
influence policy positions and policy change
of the Us presidential election in 2004 as being
analysts identified the tenor
strongly influenced by conservative nistuan 1ssues and perspectives (Hillygus
& Shields, 2005). There were several reasons tor this development. Membership
in
these groups had grown,
and the
demographic. By highlighting
ucorg W bush campaign
his Christian 1aitn, he used
seized
this
to his
on
this demographic
Infuences
on
lublic
135
Policy
litical advantage.
Indeed,e
polls from
the clection found that among
voters
cosidered morals to be a pressing issue for the country (about 22 percent of
rhe
total number of voters),
80 percent indicated
they had voted for Bush.
In addition, the same study notes that campaigns organized around
defeating same-sex marriage proposals in 1l US states seemed to provide
Aurther evidernce of the importance of conservative moral issues for many voters
Hilvgus & Shields, 2005). Issues such as the war in Iraq and the economy
were downplayed by a perception that voters were concerned with a need to
reinforce and protect traditional nuclear family values. Few Canadian studies
have examined religion as a factor in shaping Canadian politics.
AFinally, environmental factors can affect policy (Leichter, 1979). Walt
Suggests that these factors may be better understood as externalorinternational
factors (Walt, 1994). Some of these factors are changes in the international politicaland economic.aena that can affect the domestic policies of
states. These forces sometimes result in radical changesto national policies
For example, the economies of states are increasingly interdependent as a
result of international trade treaties such as the General Agreement on Trades
and Services (GATS) (Grieshaber-Otto & Sinclair, 2004). These agreements
integrate participating countries economies and enhance the mobility of
international capital to move from location to location. The North American
Free Trade Agreement (NAFTA) was signed by Canada, the US, and Mexico,
and integrates the economies of these countries (Grieshaber-Otto & Sinclair,
2004; Walt, 1994). Canada recently signed atrade agreement with the European
Union (the Comprehensive Economic and Trade Agreement [CETAJ)
(Walkom, 2014), and the Trans-Pacific Partnership (TPP). These agreements
may further commodify different health goods and services by identifying them
as sites for investment. Such trade agreements have implications tor national
policymaking, and this is especially the case for health care and health-related
policy. These issues are taken up later in this book.
Some analysts suggest that increasing int rdependence between nations
may be jeopardizing_democratic processes. This may be occurring because
CVilsociery actors are losing the ability to influence
national policies,which
are increasingly required to meet the requirements of international trade and
capital mobility agreements (Teeple, 2000).
Leichter's framework therefore provides a useful conceptual tool tor
Irying and classifying_varioustypes of influences on the political system
related public policymaking, It enables both the identiication and the
cAamination of broader factors that can infuence the public policy process and
public policy change outcomes.
Health Policy in
136
Canada
Leichter does not explicitly consider the important role that
sOcicty
actors play in policy change or the impact of political ideolo
public
interests influence
Nor does he consider how structures and
public policy outcomes. For example, the development of medicate
policy.
was not
solely about the forging of an agreement between the medical merofessi
and the government, as Tuohy (199) suggests. Ihe establishment of me
was also an achievement for the working class, which pressured for socialnedicare
in the immediate postwar period (Teeple, 2000; Armstrong &
2003,
2010). Returning Second World War veterans wanted something in return
tor
Armstrong,
their sacrifices, and governments felt obliged to respond to these demands
and financial resources were available. In addition, Canadians who had sufered
deprivations as a result of the Depression of the 1930s wanted increased seciusi
during periods of unemployment. These civil sociery actors advocated for social
change that would improve their living conditions.
And while many changes in the international and haional political arenas
have impeded the capacity of civil society actors to influence policy, these
individuals continue to try. This is particularly the case in the health policy field,
As will be seen, the motivations and interests ot civil society actors are increasingly
in conflict with international market forces. The outcomes of these conflicts will
shape national health policy as well as the health status of a population.
Easton's Framework and Its Implications
Easton (1965) presents an analytic framework that contains many institutions
and processes concerned with what he terms the authoritative allocation
of values for society (see Figure 3.1).(Valuesrefer to those objects that haxe
meaning for people. These can be material consumer goods, such as home
appliances or cellphones, or services, such as educational opportuniries or
health care. They can also be symbolic or spiritual entities, such as the right to
free speech or a tair trial, or other rights citizens expect in a democratic society.
Inputs
Eactan
identifies inputs
into the
political system as values, demands, support,
and resources. Governments select wnich o these inputs they will afford greater
attention to and which they will gnorc. 1hese choices then shape their process
of making or changing policies.
ir
Influences
on
Public
137
Policy
AMore explicitly, demands represent the expressed wishes of groups who
rticular policies that address their own objectives and interests. In
che health care arena, for example, this could be a health coalition demanding
rhat governments not allow public financing to private health care providers,
a rhat governments ensure universal access to all health care services. It could
alko include efforts to have the government develop a policy to ensure universal
access to
prescription medications
and dental
care
services.
Resources refer to the means available to governments to address_phe
made by these interest groups. Does the government have the
fAnancial resources or policy levers tO gain such resources in order to provide
demands.
public acceptance of these demands.
needs to respond to these demands?
there any reason thàt the gövernment
these services?
Support reters
to
Is
the
The State
Easton's
The middle box of Easton's model represents governmentinstitutions.
initial insights concerning the various forms of the welfare state seem especially
relevant here. Social
democratic, conservative, and liberal welfare states
are
shape the
guided by fundamentally different sets.of structures and interestsinthat
each regime.
development of institutions, values, and ideological principles
These factors cometo infuencestate receptivity to various policy directions.
welfare state
Brieftly, Figure 5.1 lays out the fundamental forms that the their
interest are
guiding
industrialized nations. Of particular
takesin wealthy
Canada is a liberal welfare state
principles and dominant institutions.
is the markerplace.
Arnaud 8 Bernard, 2003). The dominant institution
(Saint-
Liberal
welfare states generally provide the least support and security totheir citizens.
ideological inspiration is
intervention in the workings of
liberty, which leads to minimal government
Within this framework, the
the marketplace (Saint-Arnaud & Bernard, 2003).
liberal
Within
welfare
states,
the dominant
as a source
to the marketplace
Canadian
governments
of
Increasing receptivity
needs
In terms of meeting the
10r health care
policy ideas can be understood.
on
O Cizens, the greatest focus is
and
Ireland
are
the
most
deprived. Canada, the US, the UK
welfare
the best exemplars of this form of the
state.
states.
social democratic welfare
opposite situation is seen among
ne ideological inspiration for the central institution of these nations-the
ne
Rather than
e1
the
reduction of poverty, inequality, and unemployment.
most deprived,
the basic needs of the
governments
meeting
the
With
righis o
EniZing principle here is universalism and providing for the social
in
Canada
Policy
Health
138
State
W
in Forms
Figure 5.1: Ideological Variations
e
l
f
a
r
e
of the
Latin
Conservative
Liberal
Social Democratic
Solidarity
Liberty
Equality
Reduce:
Ideological
Minimize:
Government
Poverty
Inequality
Unemployment
Inspiration
M a i n t a i n :
Social Stability
Wage Stability
Interventions
Social
"Disincentives" to Work
Integration
Rudimentary
Insurance
Organizing8
Universalism
Social Rights
Principle
Access to Benefits
Residual
Taking Care of
Essential Needs of
the Most Deprived
and Familialistic
Depending on P'ast
Contributions
(Means-tested
Assistance)
Risks
Focus of the|
Needs
Resources
Programs
Family and Occupational
Central
Categories
Market
State
Institution
Source: Saint-Arnaud,
analysis
of the welfare
S.,
Convergence
& Bernard, P (2003).
regimes
countries.
in advanced
or
resilience?
Curent Sociology,
Norway, and
all citizens. Denmark,Finland,
Sweden
51(5), 504.
are
In these nations, private
the best
exemplars of
involvement
this form of the welfare
been strongly resisted.
care delivery has
state.
A hierarchical cluster
in health
superior
and Latin weltare states provide
liberal welfare states,
to their citizens than do
social
and
security
economic
1999).
democratic nations (Esping-Andersen,
but rather less so than social
and social integration is accomplished
Maintaining social stability, wage stability,
The
somewhat
conservative
based
by providing benefits
and occupational categories
on
geared to a variety of family
Bernard, 2003). These states
insurance schemes
(Saint-Arnaud &
have also tended to resist private involvement in health care delivery.
Within the welfare
differing policy
state
approaches
receptivity to
Nations already focused on
typology, differences in
can
be understood.
state
the market as the dominant institution in society will have greater diffhculty
resisting private involvemnent in health care delivery. The issue of welfare states
and their influence on health-related public policy is considered in greater
detail in
a
later section of this volume.
InAuences
on
l'ublic
Policy
139
Outputs
The outputs in Eastons model are those goods and services that the government
agrees to provide. Ihese will involve all the issues related to how health care
i e s are organized and delivered. Thcse issues involve macro-, mes0-, and
micro-level decisions that concern all aspects of how health care is delivered
vizhin a nation. Ihe details of the history and present configuration of the
health care system in Canada are described in the next chapter.
Evaluation of the Leichter and Easton Models
Like Leichte, Easton provides useful tools for identifying_andassessing
inputs and policy ourcomes. However, Eastons model focuses primarily on
stateiastitutions and too little on categories of actors and other influences on
the political system. These models are primarily concerned with the political
advocacy activities ofexperts, with a focus on state responses. There is little
consideration of the structures and interests that influence policy outcomes.
In addition, the models seldom consider the political activities of other civil
sociery actors as contributing to and infuencing the policy process. Civil
sociery organizations, such as social movements, are either absent from these
theories, or they are described in generally apolitical terms, strangely unattached
to the political process. In short, these models may provide helpful tools for
evaluating public policies, but they are static and fail to capture the conflict
that is inherent in public policy discourse.
The health policy field comprises a wide range of government, corporate,
health profession, and citizen activists and groups that bring their knowledge
of iasues and policy proposals for consideration and implementation. Citizen
coalituons torm to address pressing political issues and have been particularly
infuential in directing attention to issues of access to care and the sustainability
of the public health care system. Such groups play an important role by intorming
and educating the public about key health issyes, usually related to access, and
advocating policy solutions to ensure universal access to health care services.
CIVIL SOCIETY AND HEALTH POLICY
Civil
SOCicty refers to politically engaged citizens, professional policy analysts,
43Cational networks (such as unions and other social movements
Health
olic y in
(,anada
140
decisions (Walzcr, 1995). Social
policy
public
to
out
that attempt
formed with the explicit purpose of carrying
organizations
are
time,. 'The
for extended periods of
c o m e to exist
intuence
movements
collective action.
They may
labour, and
environmental,
womens
also includes
Civil society
communities
and
act
may
promote
change
have
coalitions that
care
organization
played by these
Society and
of social
and
Social
(1995)
Putnam's
analyzes Foley
also
theorists
a
movemen
ents
that advocate and
state
apparatus among
is health
movement
public approach
consider
as
to
hcalth
the important role
in the political process
(see Box 5.3).
Capital
controversial
work
on
social
capital and his
He
States.
in the United
decline of social capital
the
concerning
Putnam. Putnams definition
examines
arguments
Few
such
larger social
social
type of
in support of
together
and provision.
the
within
relevant
civil society organizations
Box 5.3: Civil
Smith
come
with
organizations
Intormal
champion policy
especially
s e r v a n t s . An
senior civil
good examples.
faith
These institution
ons
(Bryant, 2001).
in partnership
also form
can
are
networks
and relational
institutions
the
form outside
health policy change.
state
to
associations
educational
and
movements
capital
norms
and
reters
Edwards's
social
to
of reciprocity
networks,
and the
that
response
sense
some
to
connections between
of trust that develops
equate social
individuals,
between them
capital with
"civic virtue."
He notes
"more
(Putnam, 2000).
civic virtue and becomes
social capital highlights
that
Putnam argues
social relations
a dense network of reciprocal
it is embedded in
when
powerful
virtuous but
In contrast, a society with many
176).
173,
(Putnam, 1993, pp.
social capital. Putnam
does not necessarily have abundant
isolated individuals
fewer people join
of social capital in American society as
laments the decline
as they once had in droves in previous generations.
community organizations,
In response
society
to
Putnam,
Foley
(Foley & Edwards,
and Edwards
identify
1996). Civil SocietyI is
two concepts
based
on
de
of civil
Tocquevilles
of American asociational life to democratic
the contributions
argues tnat apolitical associations that intersect
governance. This approach
confiict within a society help to cultivate the qualities
with major lines of
work
on
needed to
develop
a
sense of community that are essential
for
efficient
democratic governance. Civil society, then, solely comprises organizations
that mediate social and political divisions, and excludes organizations that
acter social and political cleavages. vI DOCICIY i s dehned as consisting of
social
nolitically mobilized
n e usual
actors outsiae
political
associarh.
ns.
Infuences
on
Public
141
Policy
Foley and Edwards argue that "lde] locqueville ... identified specifically
nolitical associations as essential features of the rich associational life that
he observed in the United States in 1832 (Foley & Edwards, 1996, p. 42).
Foley and Edwards argue
that both versions of civil
society fail
to
consider the
Dolitical factors that inffuence and explain where or how civil society meets
the political order. Both exclude "the nature and form of explicitly political
institutions-including electoral systems and political parties-that structure
relations between citizens and the State" (Smith, 1998, p. 93). Moreover,
excluding political organizations from conceptualizations of civil society
formation.
seriously downplays critical sources of civil engagement and social
transnational
Smith suggests that this observation can also apply to studying
arena
political associations that function in an increasingly global political
(Smith, 1998). She argues that transnational social movement organizations
in fostering social capital, even in the
that they do not engender face-to-face contact among members.
similarly play an important role
event
literature. Much has
The concept of social capital has been poorly defined in the
is not
to the point that it has little meaning and
been attributed to social
capital,
the issue is
a useful analytic tool. But, as Muntaner (2004) compellingly argues,
not social capital, but class solidarity in identifying the public good and working
together to advance public policies to achieve
social and political change.
ADVOCACY GROUPS AND THE OPPORTUNITY
STRUCTURE
to
theory and research is their failure
(Giugni,
Consider the outcomes and consequences of social movements
or
1998). In other words, few studies consider the impact of social movements
(Anyon, 2014).
on
politically cngaged civil society organizations public policy
A fundamental
his is
a
problem
peculiar
with much
gap in the literature,
given
that many social
movements
become politically engaged in their efforts to promote policy change.
and their
impacts
is the
early work on social
Einwohner, & Hollander, 1995).
political opportunity s t r u c t u r e (Burstein,
social support
to the larger context of
Ihe political opportunity structure refers
resource to achieve political objectives,
a
and alliances that can form as political
devise many different strategies to
Social
change,
policy
including
their capacity to
this theoretical perspective analyzes
increase their impact, and
achieve their objectives.
with allies and opponents as means to
A focus of
movements
movements
broker activities
Health Policy in
142
(Canada
how social movements achieve their ends
in different countries. How is it that
Ocher perspectives consider
their efforts
through comparisons of
pressures? What
in shaping public policy in differing
movement activities play
social
do
role
these differing scenarios?
lessons can we learn by studying
jurisdictions? What
enables explicating how the
that this approach
argues
(1998)
Giugni
of m o v e m e n t s on
and perhaps mutes, the impact
context mediates,
political
and understand the strategies social
It is important to identity
health
policy
systems
in
evolve diferently
response
to
the same
outcomes.
movements
employ
to
achieve their impact.
shape what
For example, the emphasis
in the political system.
be
addressed
even
issues will
reflects the ability and
Canada and other jurisdictions.
in
bans
on anti-smoking
the negative impact
in having the evidence of
success of the anti-smoking lobby
into policy development. Twenty
on human health integrated
Social
movements
of tobacco
smoking
intluence health
policy
discourses
use
smoking
years ago,
may
inside
was
permitted in most public places,
public buildings, in public vehicles,
Contrast this
success
and
but current bans prevent
or on
commercial
flights.
related
anti-poverty community and
and
have the health impacts of poverty integrated
with that of the
social movements failure to
and health discourse
A
applied in the service of policy development. poverty
a structural
n u m e r o u s difficulties in having
in Canada is very rare and reflects
approach
to
integrated
health determinants
into
health
policy development
and application (Raphael, 2007b).
MEDIA
The media are a critical infuence on public policy activity within a society. The
media play an important role in identifying-and may play a roleindefining
whatissues are health policy issues. The media usually claim to be impartial and
would have us believe that they take seriously their responsibility to present a
variety of perspectives. In reality, the media rarely present all views
especially when dealing with health policy issues. It has
on an
issue,
been argued that their
health care
instrumental in creating publiC
nercention of numerous health care criSes, Where
in
reality such crises do not
exist. And, as with most instituuons in modern
media activities--like
more likely o reflec the SOCiety,
views of
ruling clites. than an
of the evidence available.
selective coverage of
issues
Jhas been
objective presentation
A
set
of articles
on
determinants demonstrates
media
not
coverage and
only
the
persistent
understanding
understanding
ases
of the
of health
media, but
Intuences
lublic
on
Policy
143
lity to shape public perceptions (Hayes et al., 2007).
also their ability
Of 4,732
an daily
from 13 Canadian
newspapers that considered the determinants
hcalth and diseasc, 6 percent of these stories were on health care topics,
ch as disease treatments, servi provision, and health care rescarch. Only
storics
3 percentof stories were concerned with physical environments and their
effects on health, and only 6 percent considered the cffects of socio-cconomic
circumstances on health
(Hayes et al., 2007).
Issues such as income, housing insecurity, and working conditions and
their impacts upon health are unmentioned. Considering the explosion
of research demonstrating that these issues are the primary determinants of
health and disease, the results of the study are rather disturbing (Marmot
&Wilkinson, 2006; Raphael, 2004, 2011). Health reporters' understandingof
these issues was either lacking or undeveloped (Gasher et al., 2007).
The media's focus on health care contributes to public perceptions
unaware
concerning the determinants of health. Canadians are strikingly
Health
of the primary influences on their health (Canadian Population
discourse
2004). It is not surprising, then, that the health policy
circumstances as
is strikingly devoid of any mention of socio-economic
health (Legowski & McKay, 2000).
being important determinants of
associated lack of public activity to raise
the
and
this
ignorance
Considering
these isues, it is not surprising that health policy in Canada is undeveloped
Initiative,
compared
to
other
developed nations
in
addressing them (Raphael,
Mackenbach & Bakker, 2002).
health
2007a;
has been
care
with
effect of the media preoccupation
care system.
of the public health
sustainability
the
concern
about
crcasing
and in some
not out of control,
is
Canada
in
Cdnty, health care spending
the past
been stable during
levels with the system have
Another
Satistaction
nts,
cade
(Organisation for Economic Co-operation and Development, 200
times
as a
grave
highlight wait
front-page
requent
with
t
politicians
Canadian
preoccupation of
Care crisis have led to the
Statistics Canada suggests tnat
policy priority.
the
health
a
as
times
Wait
be influenced by
headlines that
Ne
wait times for
and the
PCCptions regarding
policymakers
both
to this issue by
fuel support for
Cus and attention paid
hadle
may
perception
media (Statistics Canada, 2006, p. 5). This
rallel health
rationale for a parallel
The
cvidence
care
c developnenL
parallelprivate
C system
that ind
is
to
relieve pressure on
a
system
Perception
may
system
the public
system.
is
While there
opposite-that
will do the
serves
private, for-profit health care.
is, it will increase
those who wish
the interests of
to
Walt
introduce
in
Health Policy
144
Canada
POLITICAL IDEOLOGY
In addition to the activities of social movements and embedded interests,
political ideologycan playa role in shaping health policy. Existing at an abstract
level, societal acceptance of
one
political ideology over
another
can
serve as a
potent stimulus to policy development. This may especially be the case in the
health policy areas (see Box 5.4).
Box 5.4: The Patient Protection and Affordable Care Act,
or Obamacare
As an example of how structural factors can aftect the organization of the
health care system, consider the United States, which has a private health care
system rooted in its free-market economic system. Instead of having a public
health care system primarily organized by the state, which is the case in every
other developed nation, he US has numerous private insurance plans that
provide differing levels of health coverage.
Prior to 2012, private health insurers in the US tended to be managed care
(Hall & Lord, 2014). Managed care refers to a type of insurance that restricts
which doctors or hospitals will be fully covered. This includes negotiating
discounts with physicians and assessingg medical necessity of treatments that are
covered. Over half of Americans had private insurance. Private health insurers
engaged in a practice known as medical underwriting, in which they screened
potential applicants for health status. Upon the identification of a previous
health condition, insurers declined coverage to people with costly medical
conditions, charged them more, or denied them coverage for their existing
health conditions. This left about 15 percent of Americans (approximately 50
million people) without any health coverage
Most Americans had some form of insurance coverage, but
many
paid
additional health care costs that were not covered by their plans. Only a small
nercentage (6 percent) of Americans had individual private insurance. The
P
remainder had health insurance through their employers.
During the 2008 US election campaign, a key feature
of Democratic
candidate Barack Obama's campaign was health care reform
(Youno &
Schwartz, 2014). Indeed, he vowed to Dring universal health care
to the US.
Several polls showed that most Americans supporteda
health insurance program
similar
to anaaldn
2014). Most Americans considered
it
single-paver universal
(Young & Schwartz,
nedcare
appropriate
that
government shoulo
shoinld
Infuences
on
Public
Policy
145
cre aCCess to healthcare for all Americans. Indeed, a poll held just prior
ensure
o the 2008 election showed that 77 percent of all people polled-including
57 percent of those who intended to support Republican candidate John
McCain-agreed that the US government "should be responsible for ensuring"
hat all citizens' basic health care needs were met (Young 8& Schwartz, 2014).
These polls demonstrated that Americans were often well ahead of politicians
in their support of a universal health care system. It is unclear to what extent
the public policy agenda on this issue. Doubtless, it
health care retorm on the public policy agenda, but it
Dublic opinion infuenced
plaved
was
a
role in
marginal
In
to
getting
the process.
the first year of his first term in office, Obama began consultations
on
the Republican Party for a bipartisan effort
health care reform. He appealed to
to
provide health
care to
all Americans, and
to
the private health
insurance
The private health insurance industry
industry to support the legislation.
Americans to buy private health insurance
lobby called on Obama to require
to the public option that
from them (Kirk, 2010). The industry was opposed
had been proposed, and they wanted
buy their insurance from
them and
to ensure
no one
that Americans
else. In short, the
were
forced
to
industry secured
its own interests while appearing to be supportive of Obama's plan.
Under the new Patient Protection and Affordable Care Act, all Americans
must purchase their health insurance from the private health insurance
The primary achievement of the Afordable Care Act was to make
all Americans insurable (Hall & Lord, 2014). In other words, private insurers
industry.
can no longer deny coverage to Americans for pre-existing medical conditions.
Political ideology is asystem ofideasand meanings thatguides interpretation
ofevents and political action (Hofrichter, 2003). Ideology becomes embedded
n the social and political structures of a society, such as public policies and
nstitutions.
It
plays
a
key role
in
legitimating and obscuring
structures
of
p o w e r that are related to class, race, and gender (Metzaros, 1989; Deetz,
1992).poicy-makers and the publiccome to believe that the market is the best
sourcs of the means to carry out health
care organization and provision, policy
wwwie
move toward the creation of private systems or
of
Increasingly
Hivery. If policy-makers and the public believe that the primary determinants
health are biomedical
and healthy lifestyle choices, little policy
indicators
opment in support of improved living
conditions will beseen.
Clop
ealh
lnterestingly. tew political theorics consider the
ideology and pover on public peroeptions of health
P'oliy
inanaala
inthuence of
issues
and
poltca
on
pud
policy change. and on the intuence of ditkerent civil socicty organizations
on public policy. As noted in chapter 3. political economy emphasizes these
dimensions of health policy as it considers how the organization. production,
and distribution of social and economic resources intuence the organization
of the health care system and the living conditions to which the population
is exposed. The political economy approach also places these issues within
the context of dominant political ideologies and how they shape policy
understandings and policymaking.
For example. political economists have identified the rise of neoliberalism
as a significant force in bringing about economic globalization (GrieshaberOtto & Sinclair, 2004: Coburn, 2000, 2006; Armstrong, Armstrong. &
Coburn, 2001; Poland, Coburn, Robertson, & Eakin, 1998). These studies
attribute increased attention to the private delivery of health care, as well as
growing inequalities in health berween rich and poor within advanced nations
such as Canada, to neoliberal policies that emphasize a reduced state role in
policymaking and social provision.
Box 5.5: Neoliberalism: A Political Ideology of the Market
As another example, neoliberalism is defined as a political ideology that
advocates the market as the best vehicle for the production and distribution
of resources in what is termed the post-industrial capitalist economy, which
is economic globalization. Economic globalization requires the liberalization
of trade and the mobility of capital across national borders, and increased
interdependence between nations. Interdependence means that national
economies are more open to toreign investment and trade. Neoliberal ideology
provides the rationale for economic globalization (Coburn, 2000; Teeple,
2000; Schrecker & Bambra, 2015).
Increased economic
interdependence among countries has
raised concerns
about the capacity of civil society actors to innuence public
policy outcomes.
This issue is particularly salient in the social and health
policy fields, which have
last
experienced radical changes over the 20 to 30 years (Laxer, 1997;
McQuaig,
in the
1993: Teeple, 2000). In response to
global economy, anadian
changes
Canadian
governments at all levels have undertaken measures to hbalance
budgets and
or
reduce deficits, often at the
and Social
Transfer has
expense
Soe
such social
replaced
programs. The
programs
as
the
Canada Health
Family Allowance
on
ublie
147
Pbliev
rnes
and the
the Canada Assistance
Program and
funding
Plan. The transfer provides block
rtor health
and social services. Some observers perceive such changes
health anc
economic
activity
Tecple,
enhancing
as
increasced global interdependence undermining the capacity
Ochers perceive
to make domestic policy, thereby diminishing
af domestic governments
both state and civil society actors (Teeple, 2000). Both
he infuence of
conmmitments. Those who support
nenpectives reflect ditterent ideological
ot international economic activity support neoliberalism.
rhe enhancement
neoliberalism retlect another political ideology, such as social
Opponents to
international
(Laxer, 1997:
2000).
as
democracy
(which
is pro-redistribution), and
committed
are
to
reducing
public policy
groups and maintaining public
of neoliberalism as an ideology has influenced the
decisions. The spectre
in Canada and elsewhere.
dedine in social programs
role that ideology can play in legitimating
This perspective highlights the
(Howe, 1994). Political ideology is
of
voice in
a
inequalities berween
inequality
and reinforcing systems
can
conceived as tied to economic relations. Ideology
economic relations. For
of inevitability of existing
help to promote a sense
example, the power of
somehow
ability to promote economic globalization
or
can suppress other ideologies
inevitable. A dominant political ideology
those that conflict with the ideas
situations,
particularly
for
social
xplanations
health
Harden's (1999) examination of
promoted by the dominant ideology.
of the
the 1990s shows how the agenda
care restructuring in Ontario during
in the
health care and politics
altered
Revolution
radically
Sense
Common
market
as
neoliberalism lies in its
to
the idea of c o m m o n sense
province. The government appropriated
voters.
to Ontario
them more palatable and acceptable
he
of individualism that
an ideology
terms
t promoted what Howe (1994)
Hutson
commonsensically true" (p. 10;
describes as so influential "that it is
with common sense
ideology
a
political
Jenkins, 1989, p. 115). Equating
their policies and make
makes it especially powerful.
The broader
political
context takes into
opinion. As demonstrated
4
For
t
example,
account
here, ideology can
the
while globalization and
inevitable,
they
may
as fact
what is presented
defined
influence what is
perceived
be seen
as
need for deficit
constructions
of
be presented
C
an
C SOcial
world asserted by certain groups in society. By examining specin
as
chang
policy
of civil society in
as the
policy
factors, Such
tn
structural
be identified and explained. Other
can
the labour force OB
Omic base of a country, the way in which
changes tnat
or
policy
the
of
types
affect
otthe state, can
$ocial
r
change, the role
the
Is
C
Health Policy in
148
CGanada
example. if a country's economy is mixcd, as it is in countrics with associal
democratic welfare state, the role of the state is larger than in a country
with
a laissez-faire or market approach. With the advent of the welfare state
in
Western countries such as Canada, the UK, and western European
intries
following the Second World War, the state became involved in health
housing, social welfare, and other social policy areas that had been consideted
the responsibility of private charity or the market. Problems such as poverty
or the inability to find appropriate, affordable housing shifted from private
problems to public issues, and hence it became the responsibility of the state
to respond.
As an exampleofa political economyanalysis, the Canadian Centre for Policy
Alternatives examined the potential implications of the General Agreement
on Trades and Services and the North American Free Trade Agreement for
medicare (Grieshaber-Otto & Sinclair, 2004). Coburn attributes the decline of
the welfare state and changing class structures in advanced capitalist societies
to neoliberalism (Coburn, 2000). Political economy presents issues concerning
the system of production and distribution as social processes that reflect the
dominant political ideology. We live in a capitalist society, and the dominant
ideology refiects the interests of the capitalist class-that is, those who own
the
means
of
production and distribution and employ those who will produce
goods and services to earn an income.
Although chapter 11 will pick up these issues related to the impact of
globalization on health care and health policy in general, it is important here
to note the importance for civil society groups to understand the influence ot
political ideology, particularly neoliberalism, and its implications for domestic
health policy and their ability to infuence national health policy.
INFLUENCE OF HEALTH COALITIONS AND HEALTH
PROFESSIONS
THE
Canadian Health Coalition ana reated provincial health care coalitions
have lobbied the government about the importance of
maintaining a public
The
rather
than
private
approach
nared studies and reports
o
ue
ploS1On
to docunicht
c
of health care.
Concerns about
They
medicare
the problems that people face trying to access health care services.nedicaro
have
and
Inffuences
on
Public
Policy
149
e been joined
in their concern
by numerous nurses' associations,
h e Canadian Nurses Association. Such support, however, has not
beer
forthcoming from mainstream physicians
organizations, including
Canadian Medical Association, which have increasingly stressed private
a0Droaches to health care organization and delivery.
Medicare proponents now often compete with powerful lobbies such as the
corporate sector and physicians associations. The influence of these powerful
the public policy process canno be underestimated. Although all
groups on
health professions have associations that protect the interests of the professions
rhev represent, the health professionsarenotequalintheir abilitytoinfuence
public policy
The corporatesectorand physicians.associations.are powerftul lobbies that
have already significantly intuenced
these sectors possess substantial
lobbies to protect their inerests.
the direction
resources
of health discourses. Both of
that enable them
to mount
Corporate and physician groups sometimes work in tandem
to
effective
achieve
a
particular health policy outcome. For example, the new program to inoculate
all 13-year-old girls in Canada against the human papillomavirus with Gardasil
reflects the capacity of the corporate sector to lobby the political system and
the lack of definitive evidence
create new markets for its products. In spite of
to
of the cost effectiveness of the vaccine as compared to other approaches
to
disease prevention, the federal government is financing provincial progranms
cervical cancer
vaccinate all adolescent girls against the virus believed to cause
(see Box 5.6).
Box 5.6: How Politics Pushed the HPV Vaccine
By André Picard
The Globe and Mail
Snce
g
that
triumphantly unveiled in 1955
the Salk vaccine
was
would end the
scourge
unding
a
vaccine
as
of polio has there been
there is today about
one
that is
naving potential to eradicate cervical cancer.
ke polio, where children were dying and crippled
z a t i o n stopped an epidemic
as
as
much hoopla
being
in
in its tracks, cervical
the miracle
touted for
large
cancer
m
numbe
develops
y a n d the positive or negative effects of a vaccine for human papu
*V,which can cause
cancer
of the cervix, will
not
be seen for decades.
Health Policy
150
in
Canada
There remain many unanswered questions about the vaccine: Will it actually
prevent cervical cancer or just prevent infection with some strains of the virus?
.. Conservative politicians have embraced the drug as a means of bolstering
their street cred, and winning women's votes... [O]n March 19, during his
budget speech, Finance Minister Jim Flaherty short circuited the scientific
and economic discussions by announcing $300-million to kick-start an HPV
vaccination program.
Ottawa's move stunned public health officials, as well as the provinces.
"Aside from the polio vaccine in the fifties, it was the first time that the federal
government made a direct medical decision," said Noni MacDonald, an
infectious disease specialist and professor of pediatrics at Dalhousie University
in Halifax. "Why are politicians making medical decisions? This is not how
health-care delivery should be decided."
Anne Rochon Ford, coordinator of Women and Health Protection, agrees.
The lack of transparency in a program that could have a dramatic impact on
women's health is troubling, she said, and doubly so because governments
seem to have succumbed to backroom lobbying from the massive marketing
campaign of Gardasi>'s maker, Merck Frosst Canada Ltd., and its international
. Ms. Rochon Ford said the rhetoric about the vaccine wich no longterm track record has been unbelievable, and the media has mindlessly and
uncritically parroted outrageous claims, while ignoring the importance of
proved measures of reducing cervical cancer like Pap testing.
The result of all the attention to Gardasil has been to drive public demand. A
poll released earlier this week showed that 81% of parents want their
get the vaccine and 77% favour a universal,
here is a milking of
What has
public
to
of cancer
bought
Source:
happened
politicians,
and
into
Picard,
it,"
A.
along
with some
Ms. Rochon Ford said.
(2007, August 11).
Al, All.
How
other
daughters
school-based program....
sentiment around the fear
well-meaning people,
have
politics pushed the HPV
vaccine. 7he Globe and Mail,
years, both sectors have publicly expressed
acceptance
of private sector involvement in the financing and deliverytheir
of care.
At its
of care. Ar its
the Canadian Medical
annual meeting in 2007,
(CMA) voted
voted
to practise in both the
physicians
public
allowing
and the private
to support
Also, in
recent
Association
Infuences
on
151
Policy
Public
ns(Canadian Broadcasting Corporation, 2007; Priest, 2007). Although
he motion violates the provisions of the Canada Health Act, this decision
Aels
governments
efforts to
health
involvement in
care
accelerate
activities to increase
private
sector
delivery.
The Registered Nurses of Ontario opposed the CMAs motion, noting the
private health care. Conficts
and such developments provide additional
arise between health professions,
health policy development and implementation are
support for the view that
highly contested areas. Such confiict between physicians and other groups is
not new and represents only one example of a situation where physicians clearly
have greater infuence in policynmaking than the allied health professions.
vast
research
the
on
high
costs associated
with
THE CORPORATE SECTOR
The corporate sector is well organized in Canada. Through a strong network
of institutes, media outlets, and policy analysts, it advocates for greater private
involvement in all aspects of public policy, especially with regard to health
care organization and delivery. The idea of public-private partnerships((P3s) in
health care provision. is one such focus and is taken up in later sections of this
book. Box 5.7 summarizes the corporate policy advocacy network in Canada
(Langille, 2004).
Box 5.7: The Network of Corporate Advocacy Groups in Canada
Business Associations
DASZHESs Council of Canada: The voice of big business, representing the
D
CEOs of
the major transnational corporations, formerly
known
as the
Dusiness Council on National Issues. John P. Manley is president and CEO.
41adian
Bankers Association: The
leading lobby
chartered
group for the
and foreign banks. Terry Campbell is president and CEO.
1d1an Manufacturers and Exporters: Canada's oldest business lobby
is
P Tpresents large manufacturers and exporters. Jayson Myers president.
Chambers or
4adian Chamber of Commerce: A coalition of local
Ferrin
and small
presenting the interests of many large
Beatty is president and CEO.
businesses.
Heal Policy in
152
Canad,
Think Tanks
CD. Howe Institute: The voice of the Bay Street business elite, led bu .
led by president
and CEO William B.P. Robson.
Fraser Institute: Founded in 1974 by Michael Walker to represen t
right devotion to free markets. Niels Veldhuis is president.
Institute for Research on Public Policy: A liberal response to the ecomoms
omic
challenges of the 1970s, allowing more scope for government. Graham
is president.
Citizens' Front Groups
Canadian Taxpayers Federation: A watchdog for the well-to-do against the
"special interests" responsible for "runaway spending." Aaron Wudrick is the
federal director.
National Citicens Coalition: Funded by business leaders to defend individual
freedom against government intervention. Peter Coleman is president and CEO.
Lobbyists
Lobbyists are "government relations consultants" hired to help firms increase
their infuence and gain favours from government; lobbying has become a
growth industry in recent years as dozens of firms enter the market. Examples
include Earnscliffe, GCI, Hill and Knowlton, and
Strategy Corp.
Souroe: Adapted from
Langille, D. (2008). Follow the money: How business and politics dehne
our health. In D.
Raphael (Ed.), Social determinants of healeth: Canadian
perspectives (2nd ed.) P
305-317).Toronto: Canadian Scholars' Press.
CONCLUSIONS
Numerous
complex
factors influence the
public policy development pio
inant
particularly in the development of health policy.
Important
dete
health
of
policy are the structures of government itself; the extent of the
rocess,
extentdeologies
organization and activities of civil society actors; dominant political
and the
understandings concerning health care and the determinants or
held by policy-makers and the
public;
health professions. It is clear that health
media activities;
and the influence
policy is a highly contentious po
aTe
area
Public
on
153
Policy
Infuences
Of
particular
concern should be the
of media coverage, neoliberal
impact
professions on
olitical ideology,
narrow emphasis on health
Mediacoverageiis a concern because of its
policy.
health
and its tendency to highlight health care
biomedical approaches to health,
litical ideology, the corporate sector,
and the
dominant health
Rolit
care
and
crises.
ideology is
Neoliberal
known
to
threaten
concern as it
a
represents a policy
population health..
clearly
universal health a r e and overall
approach
concerned with generating profits, and
corporate sector is primarily
be a threat to the public health care system and public
sitch a concern may
receptiveness to private
that support health. And, finally, physician
policies
is a cause for concern as physician
organization and delivery of.health _care
is clearly stronger than may be the case
infuence upon public policymaking
which tend to support public approaches to
health
professions,
allied
for the
and delivery.
health care organization
The
Few models of the public policy process
forces that shape
capture all of the
the health discourses
play a role in shaping
policy.
which policymaking
about key health issues within
and public perceptions
fears about health care and health
is made. These forces can prey on public
health
policy-makers to perceived
the
of
responses
and
shape
maintenance,
to
Numerous forces
health
policy
policy areas, health policy
issues. As with other
can
be
manipulated
of avoiding this is to be
serve particular
and recognize
of forces that influence policy change
aware of the wide range
their interests.
an agenda that supports
advocate
will
usually
that these forces
Canadians requires
the views of a majority of
Whether these interests represent
interests in
a
society. The best
means
careful analysis and refection.
CRITICAL THINKING QUESTIONS
makes
citizens feel
system that
the
about
it
What is
the political process?
little influence on
with
and
What
sengaged from the process
influence health policy?
can
citizens
2. w a t are some ways that
their voices heard?
current
resources
3
do
they need
do you think
are
to
political
make
the
political process
the public
interests of saving
forces in the
dominant influences
What
these
OW Can citizens challenge
health care system:
4
Cltizens
contribute
an
alternative
discourse
key L
health issues affecting citizens?
kee
a t kind of model would
development process works
you
devise
on
to
the
on
show how
health
policy
and
Pocy
the health
Chapter 6
oVERVIEW OF THE CANADIAN
HEALTH CARE SYSTEM
INTRODUCTION
Canadians
are
proud
ot medicare. For many, it
symbolizes what
it
means to
be Canadian. Medicare distinguishes Canada from the United States, where,
2010, about 50 million Americans (approximately 16 percent of the UJS
in
lacked any form of health care insurance coverage (Hall &
Patient
Lord, 2014). As discussed in the previous chapter, the purpose of the
could obtain
Protection and Affordable Care Act was to ensure that all Americans
population)
exists in
health insurance. It did not create a universal, single-payer system as
it is
Canada. Under Canadian medicare, Canadians share the cost of risk, and
are the
a single-payer system in which provincial and territorial governments
care services (Armstrong & Armstrong, 2003, 2010).
soleproviders of health
Health care is provided on the basis of need, not income.
Health
care
is
an
in the 21st century. A
about medicare
economic, and political factors brought
determinant of medicare is Canadian
important public policy
convergence of social,
in Canada. A particularly important
area
the
institutionalist perspective, medicare signiies
Health care is a politically
Impact of institutions in shaping social policy.
contentious policy area involving intergovernmental co-operation, and has
rederalism.
From
a
new
wrangle
Decomea political football as the federal and provincial governments Maioni,
(Mclntosh, 2004;
Ene inancing of provincial health care programs
social program, but
0L0. Ihis is so not only because it is the most expensiverelations berween tne
it reflects ongoing conflict that is intrinsic to
Decause
federprovincial, and territorial governments, particularly in the health care
policy arena in Canada.
a
200
1s
medicare
the creation of
perspective,
science
social
critical
( leepie,
and the capitalist class
icompromise between the state
represented
the health field and
a
state program in
s
weltare
es
to
Overview
of the
medical
insurance
public
ors
Care
System
163
in the province went on strike in opposition to the introduction of
in the
doctors
the
Health
Canadian
the
and
province (Tuohy, 1999). The dispute between the
in the
catchewan government went to arbitration.
Tn 1960, the settlement that emerged from thestrike, known as the Saskatoon
In1
doctors to charge patients above fees negotiated with
Agreement, permitted
In. other words, the agreement allowed doctors to
extra-bill their patients for services they provided. Both parties agreed to private
the provincial
he
government.
fee-for-service medical practice. This agreement became a template for the
in 1966 with the federal government's
when it was establis
national program
sage of
the Medical Care Act (luohy, 1999; Rachlis, 2004). Under the federal
passage
ofthe.
and territorial governments became the single payers ofa
the
provincial
nlan,
and
hospital services, with Ottawa costcomprehensive range of physicians
the
sharing 50 percent of provincial and territorial health care costs and provinces
the
andterritories paying
other 50 percent.
Association lobbied then Prime Minister
In 1961, the Canadian Medical
to
Commission to study health care, hoping
Tohn Diefenbaker appoint.a Royal
the problems associated with a publicly
the commission would highlight
In 1965, Justice Emmett Hall's
financed health care system (Rachlis, 2004).
but
supported a national medical insurance_program,
commission
not only
mental
to include home care,
program
the
expanding
recommended
it also
programs for children. These
optical
and
and
dental
pharmaceuticals,
health,
medicare.
programs are still not covered by
with the five principles ofmedicare,
The provinces were required to comply
which
and
equity
the
Box 6.1: A Brief
1947
History of Canada's
Paul Martin Sr. introduces
Doctors, insurance
00he
hospital
the first provincial
a
leader Tommy Douglas,
in Canada.
insurance program
national
by
hospital
Canadian Medical
SKatchewan's
Care
insurance
it.
big business fight against
al publicly funded
Association opposes
NDP
introduces
the first
government
by
comprehensive national health
public
health
after 3
weeks.
but the strike collapses
universal and
Hall callsfor a
program. Doctors walk out,
Emmett
Commission headed
0ARoyal
program.
companies, and
health care.
1962
access
Health Care System
led
The Saskatchewan Government,
introduces
1957
ensure
national standards for health care_programs.to
the country (see Boxs1).
in health care services across
were
insurance
program.
Health Policy in Canada
164
1966
with
national medicare program
creates a
Parliament
health
50% of provincial
and
from 50:50 cost-sharing
Trudcau Liberals
1978
block funding.
to
Doctors begin cxtra-billing
1979
Canadian Labour
to
fight
paying
Dav
costs.
1977
retreat
Ottawa
Ottawa
Congress
replace
it
with
raise their incomes.
convenes
extra-billing and joins
the S.O.S. medicare conferenc
with community groups to
form the
The Clark Conservative government in
Canadian Health Coalition.
into federal
Emmett Hall to chair an inquiry
Ottawa invites
financing
1980
1984
Justice
of health
care
and how the
provinces
use
these
transfers.
releases his second Commission Report
Hall
Justice
user fees.
abolition of extra-billing and
recommending the
Parliament. ExtraCanada Health Act is passed unanimously by
Emmett
billing is banned.
government grants
1993
Mulroney
1995
name drugs.
Paul Martin
20-year patent protection
to
brand-
Health and Social Transfer
Jr. introduces Canada
transfer payments
(CHST), causing massive cuts in
to
health and
social programs.
1997
National Forum
include home
Health calls for medicare to be expanded to
pharmacare, and a phasing out of fee-for-service
on
care,
for doctors.
1998
Premiers demand say in
interpreting the Canada Health Act. Chrétien
caves in.
2000
2000
Ralph Klein introduces legislation to allow private hospitals.
Federal Budget offers 2 cents for health care for every dollar of tax
cuts, ignoring pleas of Canadians to save medicare.
2002
The Romanow Royal Commission on the Future of Health Care in
Canada conducted cross-country public hearings. Final report was
tabled in Otawa on November 28, 2002.
2003
First Ministers' meeting results in a new "Health Accord." Targeted
funding in key areas (as prescribed by the Romanow report) shows
promise. However,
there
are no
accountability mechanisms
and
no
restrictions on public funding being spent on for-profit health care.
2005
Jacque Chaoulli (backed by the Canadian Medical Association) wins
Supreme Court of Canada case. Evidence from the lower courts w
ignored. It resulted in increased calls for a two-tiered private insurane
and
for-profit health care delivery.
O v e r v i e w
ofthe
Health Care System
Car
165
CMA clects Dr. Brian Day as President and begins a highly public
2006
2006
break Medicare and allow
extra-billing and doubledipping doctors. The split within CMA leads to the formation ofa
A-year
push
to
organization:
new
Canadian Doctors
for Medicare.
Ontario doctors elect a pro-Medicare doctor, Jeffrey Turnball, as
2009
candidate for CMA President in 2010. Outspoken advocate for
private, for-proht
health care, CMA
past-President Dr. Brian
Dav
faces serious charges in a BC court, including illegal billing practices.
CCanadian Health Coalition. (2009). A briefhistory of Canada's health care system. Retrieved
from www.nmedicare.ca.
FEDERALISM: CATALYST FOR INNOVATION?
Federalism is
a
development of health care in Canada
Lavis, 2001; Mclntosh, 2004). The institution of
lead to a focus on particular issues while obscuring
critical element in the
(Hutchison, Abelson, &
federalism has tended
to
view Canadian federalism
key health care issues. Some policy analysts
for
constrained and facilitated innovation and opportunities
as having both
2001).
et
change (Tuohy, 1999; Hutchison al.,
between federal and regional/subFederalism divides political authority
be
other
national governments
the property
state
of
is considered
and
(i.c., provinces and territories)
constitutions
(Brooks, 1996). This
institutionalizes
power. Federalism
means
to
that it is based on
them to different
regions by relating
have
constitutional
governments
governments. The federal and regional
authority
r e v e n u e s . In other words, political
enact laws and collect
to
authority
of a federal
results from the acceptance
that
The
regionalism
ISdecentralized.
rivalries berween
the political administrative
is
Constitution
reinforced by
nd regional
2
governments
that
gave rise to
it.'
stems
of
In Canada, much
from the Constitution,
between the two levels of government
of each level of government.
S e t s out the powers and responsibilities
Lls
tension
ections 91 and 92 of the Constitution Act
a n a d i a n Constitution contributed to,
Cn
the federal
and the
and
intensified,
governments
provincial and territorial
the
ivy
by investig
Health Policy in
166
responsibility for health
care
Canad
the latter. Ncither th.
the cfederal nor
provision in
have exclusive
lusive constitutional
governmcnts
co
territorial
and
the provincial
for health
care
(Commission
on
the
he
Future of
of Hcalth
Hcalth
"T Care in
responsibility
n
Leeson, 2004).
Canada, 2001; Braen, 2004;
Canada. 2002; Statistics
Constitution Act, 1867, and tho.
91 and 92 of the
in sections
set out
sections, provid., the
governments' claims f a
these
of the meaning of
constitutional interpretations
territorial
and
for the federal and the provincial
2004). While these ections
in health care provision (Mclntosh,
role
continuing
of each governme
exclusive and shared responsibilities
to present the
core
appear
this is
the case. There is
not
some
ambiguity which has contributed to tensions
between governments.
Mclntosh
Canadians
(2004)
now
notes
that
consider valid
the health and social services that
of state involvement in actual delivery or
most
areas
of
of charitable or religious
In the 20th and
organizations-that is, private matters-in the 19th century.
regulation
considered
were
to
responsibility
be the
21st centuries, however, the state role evolved into these areas. The courts
increasingly determine which level of government is responsible for specihic
policy initiatives.
In health care, the provinces and territories have primary responsibility
for the organization, administration, and delivery of most health care services
(Braen, 2004; Leeson, 2004). Section 92(7) of the Constitution Act, 1867,
-
supports provincial responsibility over the administration and delivery ot
health
care
services, but many constitutional
provisions authorize provinia
responsibility in this area. The federal government has a role in criminal law
patents, and its often controversial spending power. The original act does not
identity
the
territories, but territorial governments have the
provincial governments.
same
powers a
The
its
tederal government can intervene in health care
only
throug
spending power. It has used this power to set the terms and conditions of
medicare. Although since the 1980s it has
nster
its
reduced
consistently
t
payments to the provinces and territories, the
considerable control over the terms of medicare federal government rcl
al and
and also over the
territorial governments in the
provinca
administration of their health insurance plans.
p
it
Interestingly, has rarely penalized province
territory for vioa
v
principles of medicare, although some
provinces and territories have ro
allowed extra-billing and
the imposition of user fees.
The Charter of
Rights and
part of the Constitu
1982, cxerted new thrust in Freedoms,
os
public policy debates
a
or
ct,
as
a
and groups
to use
the courts in
ettorts
by
to
enabling
ina for
accountable
accounta
hold governments
Overview
of the
Canadian
Health
Care System
i
choices by
by asserting any of the
policy
choices
167
rights listed in the Charter. The Charter
has been used
to challenge the state's role in a policy area. In 2005, the Charter
used to
been
has
nrovided the basis of a challenge to Qucbecs ban on private insurance for
re-covered services (Rachlis, 2005). For some, this challenge seemed the
providec
death knell for
medicare.
Single-PayerSystem
Under medicare, the provincial governments are termed single payers for most
medical and hospital services (Tuohy, 1999; Rachlis, 2004; Yalnizyan, 2006).
Each province and territory has a single government insurance plan that provides
a
comprehensive range of medical and hospital services. From
the
outset as
insurance alternatives
the system developed, there was no provision for private
for these services. Provincial and territorial governments
were
intended
be
to
monopsonists-sole purchasers--of medical and hospital services. Monopsony
is an economic term that refers to a state in which demand comes from
one
source
good,
(Tuohy, 1999).
that
customer
If there is
has
a
only one
customer or
purchaser for
for that
monopsony in the market
a
certain
good or service,
or one employer controls a sector by providing that good or service exclusively.
side, not the supply side.
monopoly, but on the demand
It is similar toa
Since the
two
inception of medicare,
levels of government
care system. The
also been
the
the
federal
were
cost-sharing schemes between the
the health
ensure the sustainability of
various
devised
to
financing of provincial and territorial
primary source of tension between
the
health
two
care
programs
has
levels of government
as
but continues to dictare to
is
are to be delivered. It
on which services
government has reduced its contributions,
provinces and territories the terms
the principles of
to
considered that the federal spending power has helped protect
the
medicare
as
intended
by its founder, Tommy Douglas (see
Box 6.2).
Box 6.2: The Five Principles of Medicare
of
have to cover 100 percent
nversality of coverage: The provinces
residents for hospital and physicians services.
to
ortability of coverage: The provinces have
cover
their residents
their
for care
They
that pertain in other provinces.
at least at
out of the country,
while
residents
PPOSCd to cover their
ates that would have applied in their home province.
C r
provinces at
the
rates
are
the
168
Health Policy in Canada
Reasonable accessibility to services: The provinces are to ensure that serviCes
3
are "reasonably accessible" and that financial charges or other barriers
do not impede access. This criterion also requires the provinces to pay
reasonable compensation to their health professionals.
Comprehensiveness of services: The provinces are supposed to cover all
4.
"medically necessary" services provided by doctors or within hospitals,
This criterion is actually a misnomer because community services (such as
home care) are not covered and neither are the services of other providers
(except dental services within hospitals -a rare event these days).
Public administration: The provinces have to administer their health
insurance programs either themselves or through a body that is
accountable to the provincial government. This criterion is also a bit of
a misnomer because it expressly forbids neither for-profit insurers acting
on contract
Source: Rachlis, M.
system
with
(2004).
a
province nor for-profit providers
of services.
health care
is
Prescriptionfor excellence: How innovation saving Canadas
(p. 37). Toronto: HarperCollins.
Cost-Sharing Arrangements
since the
arrangements have evolved and changed radically
Canada. At the outset, the focus was on financing
inception of medicare in
allied health professionals
hospital and physician services. Services provided by
had a physician's referral for such services.
Cost-sharing
were
covered, provided patients
Over time, a broader range of institutional and community health settings,
such
as
community
health
centres
that combine
health and social services,
were recognized.
In (1957) the Hospital and Diagnostics Service Act provided federaland physician services (Rachlis, 2004;
provincial cóst-sharing of hospital
Tuohy, 1999). This act provided a template for tuture health care programs
(Rachlis, 2004). The federal government contributed 50 percent of the costs
of these services. The act required that provincial plans comply with the five
Drinciples of medicare: (1) universality, (2) portability, (3) comprehensiveness
administration.
(4) accessibility, and (5) public
Overview of
che
Canadian
Health
Care System
169
Medical Care Act
Tl
1966, the federal government
implemented
the
Medical
Care Act,
hich enshrined the principle of public payment for private medical practice
LTohv,
h
1999; Rachlis, 2004). The act entrenched private fee-for-service,
hecame the
chief
mode of
practice
for the
organization of
navment in Canada. The act was considered a compromise to appease both
physician
opponents and supporters of medicare. The federal government also promised
o continue to pay
percent of the costs ot provincial and territorial programs,
provided the provinces and territories complied with the principles of medicare
(Rachlis, 2004). Under the terms of the act, which are still in force, physicians
send claims for payment to the provincial and territorial health insurance plans
(Scot, 2001). They are reimbursed on the basis of the fee schedule negotiated
by the government and medical association in each province or territory.
When the Medical Care Act came into force, only Ontario refused to
comply. All of the other provinces and territories agreed within the first year
(Rachlis, 2004). Ontario Premier John Robarts preferred a market system
similar to that of the US, whereby the government would insure only those
who could not afford private care. Prime Minister Pierre Trudeau threatened
to withhold thetransfer from Ontario, forcing Robarts to agree to the federa
formula in 1971
Some attribute the inclusion of private practice to good fiscal buoyancy/
health, positive federal-subregional (i.c., provincial and territorial governments)
relations at the time, broad political support for access to health care on the basis
OT necd regardless of income, and physicians' willingness to accept limitations
neir entrepreneurial discretion in exchange for protessional independence
n clinical decision making (Tuohy, 1999; Hutchison et al., 2001). A strong
cconomy
at
the time enabled the government
POgram on generous terms, including continued
unical
autonomy, and control
lhis
arrangement
over
the location
placed physicians
at
to
draw
physicians
into the
fee-for-service remuneration,
of medical
and
organization
the centre of health
care at
It
health care system.
became the gatekeepers of the
they
Cs.In
as this promise of power and control that ensured physician support tor the
short,
cm.
The
legislation did
not
delivery (see Box 6.3)
Oughout the 1970s and
Oncerned
the
change the existing
structure
of health
care
1980s, both federal and regional governments
iniatuOn
about controlling social spending. With growing
commitments
time, the federal
gover
was
uneasy
about its spending
Health Policy in
170
Box 6.3: Canada's
Health Care
Canada
System
health care system is best described as an interad
Canada's publicly funded
insurance plans. Knour
and three territorial health
to
set of 10 provincial
access to universal, comprehensivo
the
provides
ve
ocking
.
Canadians as medicare,
system
and physician services. These services
for medically necessary hospital
and territorial (i.e., stateor
administered and delivered by the provincial
free of charge. The provincial and
governments, and are provided
coverage
are
regional)
territorial governments fund health
care
services with
assistance
from
the
federal (i.e., national) government.
What Happens First (Primary Health Care Services)
When Canadians need health care, they generally contact a primary health
care professional, who could be a family doctor, nurse, nurse practitioner,
physiotherapist, pharmacist, and so on, often working in a team of health care
professionals. Services provided at the first point of contact with the health
care system are known as primary health care services, and they form the
foundation of the health care system.
In general, primary health care serves a dual function. First, it provides direct
provision of first-contact health care services. Second, it coordinates patients
health care services to ensure continuity of care and ease of movement across
the health care system when more specialized services are needed (e.g., from
specialists or in hospitals).
Primary health care services often include the prevention and treatment
of common diseases and injuries; basic emergency services; referrals to and
coordination with other levels of care, such as hospital and
specialist care
primary mental health care; palliative and end-of-life care; health
promotion;
healthy child development; primary maternity care; and rehabilitation services.
Fee-for-service scheduled negotiated between each provincial and territorial
gOvernment and sub-national medical associations set the fees.
Doctors in private
practice are generally paid through fee-tor-service schedules
negotiated between
each
provincial
territorial government and the
iurisdiction. Those in other practice
or
medical association
in its
settings, such as clinics, community
are
more
and
centres,
health
ikely to be paid
grouppractices,
through an alternative
as
salaries
such
payment scheme,
ora Dienaed payment (e.g., fee-for-services plus
incentives). Nurses and other health proressionals are generally paid
salaries that
between their unions and their
resppec
are
negotiated
employer
Overview of
the
when
Canadian
necessary,
Health Care Svstem
patients
are
171
reterred
to
specialist
services
(medical
cnecialists, allied health services, hospital admissions, diagnostic tests,
prescription drug therapy, ctc.).
What Happens Next (Secondary Services)
A patient may be referred for specialized care at a hospital, at a long-term care
facility, or in the community. The majority of Canadian hospitals are operated
by community boards of trustees, voluntary organizations, or municipalities.
Hospitals are paid through annual, global budgets negotiated with the provincial
and territorial ministries of health, or with a regional health authoriry or board.
Alternatively, health care services may be provided in the home or communityy
(generally short-term care) and in institutions (mostly long-term and chronic
care). For the most part, these services are not covered by the Canada Health
Act however, all the provinces and territories provide and pay for certain home
care services Regulation of these programs varies, as does the range of services.
Referrals can be made by doctors, hospitals, community agencies, families, and
potential residents. Needs are assessed and services are coordinated to provide
and comprehensive care. Care is provided
formal, informal (often family), and volunteer caregivers.
continuity of
care
by
a
range of
Short-rerm care, usually specialized nursing care, homemaker services, and
adult day care, is provided to people who are partially or totally incapacitated.
in long-term institutions
part, health care services provided
while room and board
paid for by the provincial and territorial governments,
these payments are subsidized
are paid for by the individual; in some cases
of
and territorial governments. The federal department
the
are
For the
most
by
provincial
when
provides home care services to certain
the
or territory. As well,
Such services are not available through their province
to First Nations people living
Tederal government provides home care services
veterans
Veterans Affairs Canada
on reserves and to Inuit in certain communities.
ralliative
care
is delivered in
a
variety of settings,
such
as
hospitals
or
long-
and at home. P'alliative
facilities and hospices, in the community,
and emotional support, pain
those nearing death includes medical
and programs, and
with community services
Crm care
are
for
symptom management, help
bereavement counselling
E
icalth
Canada. (2012). Canadas health
care
system.
Retrieved from http://www.nc-c
6a/ncs-s/pubs/system-regime/2011-hcs-ss/index-eng-plhp.
172
Health Policy in Canacl.
(Rachlis, 2004). The federal and the provincial and territorial governments
wanted to
adjust the
funding
the
concerns led to
rules. 'Ihese
Established Programs Financing Act in 1977.
passage of the
Established Programs Financing Act: Shift to Block Funding
In 1977 the federal governnment passcd the Established
Act (EPF). The federal government threatencd to act
Programs Financing
unilaterally unless the
provinces and territories agreed to negotiate a block-grant arrangement
(Tuohy, 1999).
A block grant or fund is a sum of
money
to another for a
specific purpose. Block
given by one level
of government
grants signified a
shift from the cost-sharing arrangements that characterized earlier
funding
arrangements in health care between the two levels of government. In other
words, federal transfers for hospials, medical care, and
education
were
placed
in
one
funding envelope
post-secondary
with
a
commitment
to
increase funding at the same rate as economic growth (i.e., the gross domestic
product, or GDP) (Rachlis, 2004).
Under the EP, federal transfers
to
health care-and
post-secondary
education-consisted of two cqual allocations of a tax transfer and a cash
transfer (Tuohy, 1999):
1.
A cash transfer was conditional on provincial compliance with the five
principles of medicare (i.e., universality, accessibility,comprehensive
ness, portability, and public administration) and was determined on
the basis of one-half of per capita transfer to a province or territory in.
1975-1976. The amount would be determined partially by the rate
of increase in GNP and growth in the population in a province or territory, but not at the rate of actual health care costs. In addition, an
unconditional transfer was provided in the form of tax points. A tax
point or tax room is fhscal compensation in the place of a cash trans-
fer from the federal government
to
the
provincial and territorial gov
ernments (Madore, 1997). Tax points lower the federal income tax
rate and the provincial and territorial governments increase their tax rates
by
an
equal
amount. For
example,
when
negotiating fiscal arrange
ments, the federal government would give the provinces and territories
the option of opting out of a program and receiving an alternative for
the federal contribution to a program, often in the form of tax transfers.
Overview
of the
Canadian
Health
Care System
173
The new funding arrangement under the EPF gave the provincial
and territorial governments greater discretion to allocate health
care funding in accordance with their needs and priorities. The tax
Doints were based on the revenues produced by a specific number of
Dercentage points of the amount of income tax of the federal basic tax
generated in a province or territory (Tuohy, 1999).
2.
The impact of the shift to tax points made provinces and territories
whose economies grew at less than the GNP financially less well
off in the short term. The federal government provided transitional
payments to prevent provinces and territories from being made worse
off than if the provincial and territorial governments had received
a cash transfer set at the rate of GNP and population growth. The
federal government reduced its income tax rates by 16 percent, and
the provinces and territories raised revenues to finance health care and
institutions (Rachlis, 2004).
Overall, the shift to block grants heightened tensions berween therwo
initiated such
federal
government
levels of government, particularly when the
Ottawas
actions without consulting the provincial and territorial governments.
and
unilateral action would become the modus operandi when the provinces
concerns in health care
territories refused to comply with federal plans. Other
also emerged.
the
of the other provinces and territories during
late 1970s, doctors grew concerned about the decline in their incomes (Begin,
In Ontario
and
some
for their work, whereas
2007). With the creation of medicare, they were paid
of medical bills were not
prior to the creation of medicare, about 10 percent
to over 10 percent,
paid (Rachlis, 2004). Yet, by the 1970s, inflation had risen
To make up the
incomes had begun to fall.
Such that
physicians'
1975,
by
fees
in the fee
above the
Lal,Some physicians extra-billed patients
who extra-billed
in their region. The percentage of Ontario doctors
cdule
20.
in 1978 to approximately
10
percent
than
less
from
Lpatients increased
set
percenrin 1979.
Crombie
of Health David
/9,
the health care system.
Emmett Hall once again to lead an inquiry on
the
new
federal
Conservative Minister
in
decond commission report. one of Hall's key recommendato
user fees (Rachlis, 2003)
Cnt to eliminate extra-billing and hospital
LS
main contention was that the two practices had led to a two-tiered health
System that jeopardized universal accessibility of health care Servi
Health Policy in
174
PROTECTING
THE FIVE
PRINcIPLES
OF
MEDICADE
Canada
AND
EXTRA-BILLING
ON
THE WAR
The
Canada Health Act
of 1984 enshrined
the ive
principles of medico..
(1)
(4) comprehensiveness. and
accessibility, (3) portability,
(2)
universality,
(Rachlis, 2004; Tuohy 1
public
and banned extra-billing
reduce its financial contrih.
to
Ottawa
that
allowed
provision
administration,
to extra-bill their pati
ents
that permitted physicians
and
territories
to provinces
1900
(Tuohy.
and territorial compliance
999).
e n s u r e provincial
It included a
as a
measure
to
The federal government
used this
act to launch its
attack on
extra-billino
The strike illustrates ow
the 1985 doctors'strike in Ontario.
triggered
the war on
rod for doctors discontent during
Ontario served as a lightning
in Ontario than in an
contributed to more conflict
which
extra-billing, as the act
1999; Rachlis, 2004). The relationshin
other province or territory (Tuohy,
and the Ontario Medical Association
berween the provincial government
confrontational. To add to existing tensions,
(OMA) was already particularly
ended the 40-year Conservative rule in
the election of a Liberal government
accommodation reached by the OMA and the
Ontario and also disturbed an
Conservative government.
the
The actions of the federal Liberal government of
early 1980s should
overwhelming commitment to medicare
on its part (Tuohy, 1999). Rather, it acted out of concern for its declining
not
be construed
as
expressing
an
issue of extra billing
popularity. As Tuohy (1999) argues, it "seized upon the
the universality of the
as a way of symbolizing its commitment to preserving
the federal
most popular social program" (p. 93). It threatened to reduce
transter payment by the amount equal to the estimated amount of extra
billing occurring in an offending province or territory. Interestingly, tne
federal government hid behind the veil of this commitment while it whittled
away at its financial contribution to provincial health care programs (Luoiu"
1999; Rachlis, 2004; Brooks, 1996).
CANADA HEALTH AND SOCIAL TRANSFER
The 1995 federal
EPF
budget replaced the Canada Assistance Plan and the
for
funding health and post-secondary education with the Canada alth and
Hca
Social Transfer (CHST))The Canada Assistance Plan (CAP) provided u
gave
for welfare and other
provincial social services (Brooks, 1996). Ine065 to
federal transfers to
provincial and territorial welfare programs fro
96
Overview
of the
Care
Canadian Health
System
175
1095 (Banting, 1997). Under the program, the provinces and territories were
required to
provide assistance to all residents in
need.
he CHST is a single block transfer that empowers the federal
government to freeze and cap the transfers to the provinces and territories that
hoth federal Liberal and Conservative governments had done since the early
1980s (Brooks, 1996). This transfer effectively ended cost-shared programs
herween the federal and regional governments and signalled a retreat from
Ortawa's commitment to national standards, which historically depended on
the federal spending power.
Box 6.4:
History of Health and Social Transfers
Health and social transfer payments have developed over the years from cost
sharing programs to block funding transfers. The illustration below shows the
evolution of those transfers.
Figure 6.1: History of Post-Secondary Education, Social,
and Health
Funding in Canada
1957-1976
1996-2003
1977-1995
2004 onward
Canada Health
Transfer (CHT)
Post-Secondary
Education Program
Hospital Insurance
Established Programs
Financing (EPF)
Canada Health and
Social Transfer
(CHST)
Medicare
Canada Social
Transfer (CST)
Canada Assistance
Canada Assistance
Plan (CAP)
Plan (CAP)
and social
c1Olowing is a brief timeline of the evolution of health
transterS
within Canada:
0 s and 1960s: Health and social transfers were either provided as Casi
social
W e T e cost-shared
n
the establishment of national
introduced,
Assistance Plan (CAP) was
to encourage
1966, the Canada
Conditions
ing a cost-sharing;arrangement for social assistance programs.
and
that provinces
Wer
to federal
including the provision
funding,
.
territory
Ories
the province
in
or
as a
residency
" Or eligibility for social assistance or for the receipt ofsocial assistancc
not
require
a
period of
Health Policy in Canada
176
1977: The Established Programs Financing (EPF) was introduced, replacing
cost-sharing programs for health and post-secondary cducation. Federal
funding provided through the EPF initially took the form of cqual portions
of a tax transfer and a cash transfer. Provinces received 13.5 percentage points
of personal income tax (PIT) and 1 percentage point of corporate income tax
(CIT), including some points carried over from the previous post-secondary
education program. Provinces and territories received equal per capita total EPF
support through a mix of cash and equalized tax points. The value of the tax
points grew in line with the economy. The growth rate of the cash transfer was
modified several times as the program underwent changes throughout the years.
1984: The Canada Health Act was enacted. EPF funding was made conditional
on respect for the five criteria of the Canada Health Act (universality,
accessibility portability, comprehensiveness, and public administration) and
provisions for withholding funding were introduced.
1995: The federal budget announced that the Canada Assistance Plan and
Established Program Financing would be combined into one block fund-the
Canada Health and Social Transfer, or CHST. The CHST provided funds to
provincial and territorial governments in support of health care, post-secondary
education, social assistance, and social services. Like the Established
Program
Financing transfer, the CHST was a combination of the 1977 tax transfer and a
cash transfer, and the total was allocated on
an equal
per capita basis.
2000-2003:
In 2000 and
2003, the Government of Canada and
provincial
governments entered into a series of agreements to
strengthen
and renew Canadas
publicly funded health care system. These
and territorial
sought to improve accountability and
agreements als
reporting to Canadians.
As part of the First Ministers'
Accord on Health Care Renewal in February
2003, First Ministers also
agreed to restructure the CHST effective April
2004, to create two new
transfers-the
Canada Health Transfer, or CHl
CST-to improve the
and
transparency
a
support to provinces and territories.
Retlecting
and the Canada Social
Transfer,
of
accountability federal
or
provincial spending patterns,
health, and the
remaining
62 percent of the
CHST
38
was
percent
was
allocated towar
allocated toward post-seconaau
education, programs for children, and
other social
programs.
Budget 2003 allocated $16 billion over
five
years through a new Iealth
Reform Transfer targeted to
primary health care, home care, and
phic
drug coverage.
catasto
of the
o fthe
Canadian
Ca.
Health
Care
System
177
O v e r v i e w
September 2004,
In
In
Care.
support
signed the 10-Year Plan to Strenether
of this 10-year plan, the Government of Canada
First Ministers
lealth
committedad
additional funding to provinces and territories for health that included
increases
to the
CHT through a
base adjustment
and an annual 6 percent escalator.
10-Year Plan to Strengthen Health Care, the Health
IInder the 2004
into the Canada Health Transfer effective
was incorporated
Reform Transfer
April 1, 2005.
the federal government's commitment
to
Pursuant
2007:
to restore
fiscal
transters to provinces and
Budget 2007 put all major
track out to 2013/14.
territories on a legislated, long-term
cash support
restructured the CST to provide equal per capita
Budget 2007
made to facilitate
halance in Canada,
investments
territories. Additional
provinces and
the stability and
this transition and to enhance
to
provinces and
territories for
were
predictability of support
post-secondary education,
Total
for children, and other social programs.
to
education programs
CST cash levels
were
also
set
in
legislation to grow by3 percent annually.
Plan to Strengthen Health Care agreement,
Respecting the 2004 10-Year
cash in 2014/15. For a
to equal per capita
the CHT was legislated to m o v e
2007
in budget planning, Budget
certainty
to
transition
and provide
smooth
transfers
also ensured that
the CST
under
2008, prior
to
no
or
province
or
CHT relative
territory would
what
to
receive lower cash
they would
have received in 2007-
n e w Equalization system
the implementation of the
cash allocation for the CST.
and
an
cqual per capita
Z009
o
The
Cnsure
same
per
U1:
2009 legislated
Budget Implementation Act
thatr Ontario,
as an
Equalization-receiving
a
technical adjustment
province,
Equalization-receiving
capita CHT cash as other
The Government
of Canada
received the
provinces.
December 2011
announced in
that the
2016/17. Starting
annually until
continue
wIll
moving averago
a three-year
with
line
in
to
2017/18, the CHT will g r o w
with funding guaranteed
growth,
to
(GDP)
continue
g r o s s domestic product
the CST will
to grow at
DY
W
at
at
least 3
Current
6
percent
percent per vear.
rate
of3 percent
In addition,
2014/15 and
annually in
beyond.
Ihe
CHT and the CST will be reviewed in 2024.
Source: Deparu
Ottawa:
nance
Minister of
Canada. (December
State (Finance).
History
15, 2014).
Retrieved from
of health
www.lin.gc.a.
and social
Health Policy in
178
Canada
CANADIAN HEALTH CARE
CURRENT ISSUES IN
Many
issues in health
care
have
arisen
Chief amono th.
has
provincial and territorial
in recent years.
been the decreasing federal contributions
to
alt
care plans. Brooks and others have argued that the federal position has
as been
to reduce its contribution toward provincial and territorial health ce
ices
while continuing to set conditions on how those services will be
be delivea
delivered
(Brooks, 1996: Armstrong & Armstrong, 2003, 2010). The reduced federal
contribution has thus been the source of much tension betweenthefedezal
and the provincial and territorial governments since the early 1980s. The
provincial and territorial governments have had to shoulder a larger share
of health care costs, which increase annually. Thus, declining federal
transfers and growing health care costs have contributed to provincial and
territorial governments opting for various privatization schemes to reduce
their health care costs, such as public-private partnership arrangements (P3s)
tobuild hospitals and other social services such as schools and highways.
Provinces and territories have also delisted drugs covered by the provincial
and territorial drug formularies and introduced user fees for a wide range of
previously insured services.
Indeed, many are concerned that the 2004 Health Accord expired March
31, 2014. The Conservative federal government did not initiate discussions
with the provincial and territorial governments to renew and renegotiate the
agreement. In December 2011, then federal Minister of Finance Jim Flaherty
announced that the 6 percent annual increase in the Canada Health Transfer
and 3 percent annual increase in the Canada Social Transfer will continue until
the 2016/17 fiscal year (Picard, 2011; Walkom, 2011). After 2017, until at
least 2024, increases will be tied to economic growth, including infation at
about 4 percent, and will never fall below 3
percent.
A majority Liberal government led by Justin Trudeau was elected in the
October 2015 general election. The Liberal
campaign
platform promised
collaborative federal leadership" (Liberal Party of Canada, 2015) and to
negotiate a new health accord with the provincial and territorial governments.
The accord will include
a
long-term funding agreement.
THE INFLUENCE OF
NEOLIBERALISM
While reduced federal transfers have indeed undermined
national standa
in health care and other social
policy fields, privatization is also driven bya
Canadian
Overviewofthe
Health Care System
179
tic of
ideological commitment char
increasing
neoliberalism
in Canada.
Neoiberalism is a market ideology in which the market
is considered
to be the
of economic and social resources
allocator of
in society
(Coburn,
of
ther
rise
the
neoliberalism
and
trace
to
Many
the
globalization
2000).
early 1970s
2000).
efhcient
allocator
ec
a
most
race
oil risis,
which prompted many OPEC countries (i.e.,
participant countries
in theOrganization of lPetroleum Exporting Countries) to ratchet back social
programs(leepl
2000; Schrecker & Bambra, 2015).
Canadian governments raised alarm bells about the sustainability of
modicare in its current form uring the 1990s and into the 2000s. The issue
of sustainability has fuelled interest in allowing private sector involvement in
h care. A key issue is how to pay for the services and programs that promote
health, and how to make it politically feasible and attractive (Yalnizyan, 2006).
Affordability is expressed in terms of ability to pay. However, governments
have not only the responsibility to pay, but also the capacity to control costs.
Government decisions have implications for the public purse and household
income, and influence total health care spending in the economy.
HEALTH CARE REFORM
Concern about the sustainability of medicare provides an opportunity
to explore how it can be reformed to best serve the health care needs of
Canadians. As noted elsewhere in this volume, Tommy Douglas and Emmert
Hall recommended broadening the programs covered by medicare to include
has
Recent interest
care, home care, and other serviçes under medicare.
dental
focused on expanding medicare to include a national pharmacare program
provide coverage of the cost of prescription medications.
At the
noted:
first SOS medicare conference in 1979, Tommy Douglas
hose of us who
tne
talked about the need for public health
1940s, '50s, and 60s
kept reminding
insurance back in
Canadians that there
were two
between
the financial barrier
need them. We pointea
tnose who provide health services and those who
faced
problems we
was the easiest of the
first
phase
that
this
pcatedly
and administrative
organizational
the
up
the
setting
revenue,
unding
would
be a
Phase 2, however,
costs...
over
controls
osts
CXercising
**.
reducc
so as to
o
system
O r e dithicult one: altering our delivery
and
phases of Medicare.
The first
was to remove
**
. . .
tment
putting emphasis
drugs.
on
yDouglas,
preventive
medicine rather
SOS Medicare,
November
than
u
on
2007)
1979, in Douglas, 2007
to
Health Policy in
180
Canada
on diagnoses and curative tre
The current thrust of the system
health care provision. Ihe system lacks a preve
has increased the cost of
view of some critics, prevention would involve add..
component. In the
determinants of health, and in particular reducing the Dover.
treatments
iressing
thesocial
among
non-elderly
families with children
to
improve
their
rate
health. Resea rch
has established the relationship between income and health (Gordon, Sha
Dorling, & Davey Smith, 1999; Brimblecombe, Dorling, & Shaw, 1990
Annals of the New York Academyof Sciences, 1999).
As noted elsewhere in this volume, Canada has signihcantly reduced health
inequalities associated with medical conditions most conducive to medicol
treatment, but has done less well in reducing income-telated inequalitiesin
mortality from causes conducive to public health interventions, such as lung
cancer and motor vehicle accidents (Bryant, Raphael, Schrecker, & Labonte
2011). The next frontier is to address the social determinants of health and
their unequal distribution across the Canadian population.
Medicare has many proponents and detractors. The latter seize upon any
perceived failing of the system as evidence of the need to privatize health care.
Both sides agree onthe need to-reform medicare, but there is no consensus.on
howto proceed. Public opinion polls show that Canadians value the health care
system and support reforming it to improve delivery Few Canadians support
privatization as a solution. In addition, some health policy observers have warned
that allowing private providers into the health care system would erode medicare
in the long term and violate the principle of providing care on the basis of
need.
They advocate public solutions to addressing problems within the system
(Rachlis, 2004; Yalnizyan, 2006; Canadian Doctors for Medicare, 2013).
WAIT TIMES
The federal,
provincial, and territorial governments
medicare. They focus their concern on
reducing
care.
Some
provinces,
such
as
continue to wrangle ovc
wait times for
specia
Alberta, British Columbia, and Ontario,
have
health services,
privatized
arguing that private sector involvement wil
relieve the backlog in the
public system. Conservative think tanks such as tnc
Fraser Institute and the C.D.
some
Howe Institute have
contributed to this view
Barua & Clemens, 2015; Robson &
Laurin, 2015).
A health care
carried
out
survey
jointly by Statistics Canada and theL
for Disease Control and
Prevention in the United States showed that 31
of
perce
ters
cent
low-income Americans
reported
poorer
health, compared
to
23
perce
of
Overview
of the
Canadian
Health Care
System
181
me Canadians (Sanmartin & Ng. 2004). Interestingly, Americans
low-income C a n a d i a n s
arelikel
likely
were more
to report being "very satisfied" with their health care services
pared to Canadians, who were more likely to be "somewhat satisfied."
m c h of this concern is perceived rather than real is questionable. A
more recent study shows that Canadians with low incomes continue to report
orer
poore
health
outcomes
overall
compared to populations with higher incomes
In
addition, cause-specific mortality is
income groups in Canada. This illustrates the impact of
highest for the lowest
status and mortality (Tjepkema, Wilkins, & Long, 2013).
income on health
(Tiepkema, Wilkins,
&&
Long, 2013).
Studies on health spending in Canada and comparison nations with or
without a public health system have shown that the public system is less costly.
for Canada, the United States, the United
Table 6.1 shows the health spending
health care is less costly. Canada's
Kingdom, and Sweden. In all cases, public
which
single-payer system,
Dublic spending on health care is equated
a private system (Yalnizyan, 2006; Canadian
has numerous advantages over
with one centre to receive bills and
Doctors for Medicare, 2011). For example,
administrative duplication. Moreover,
send out payments, the system reduces
and territorial health care costs
approximately 1.8 percent of Canadas provincial
and hospital claims.
structure responsible for paying physician
are directed to the
with the
were 17.7 percent of GDP in 2011,
In contrast, the US health expenditures
$8,508 per person,
It
outspending all other countries (OECD, 2013). spernt Health
countries.
spending in
which is 2.5 times the average of all developed
less than halfthe average annual
the US rose by 1.5 percent in 2013, which is
growth rate
before 2009.
low
experienced a sustained period of negative
Between 2005 and 2009, its
growth in its health expenditures (OECD, 2015).
or
Since 2010, Canada has
Health spending fell from 2 percent
in the 2013/14 fiscal year.
per year in the 2009/10 fiscal year to 0.2 percent
the economy.
lhese data challenge claims that health spending will bankrupt
health
spending grew 3.5 percent per year.
that require
Nonetheless, medicare has a number of issues
tnem is
wait times
n e issue
for
redress. Chiet among
specialist and primary care discussion
of wait times for
care
has led
to
about considering an
among provincial
increased role for the private
parallel private system
IOrial governments
development of a
h e a l t h care, or allowing the
Using public dollars
the pressure on the public system.
Care
cover private
Canada Health Act.
services violates the principles ofthe
o n on
h
to
breach these
the terms of the Canada Hcalth Act,
provisions risk
federal Etnment has
not
losing
acted
on
some
As noted in
provinces and
federal health
Such
these violations.
care
a
territories
dollars. Ihe
state
affair
oraldalo
182
Health Policy
dre
6.1:
Demographic Aspects of Canada and Three
in
Canada
rison
Comparison
Nations, 2010
United
Canada
Kingdom
States
GDP per capita, 2012
$44,319
$54,565
$39,561 545,813
2.6
2.3
.38
.34
27
13
16
18
2.5
2.4
Gini coeffcient)
.32
% of population >65
14
Annual GDP growth in
Sweden
United
6, 2010-2014
Income inequality 2010
years
Source: Organisation for Economic Co-operation and Development. (2014). OECD annual national
accounts database 2010. Paris: OECD.
leaves the
public wondering who will protect medicare and
there when
they or a family
Much has been written
member
on
how
whether it will be
require emergency or long-term care.
to
reduce wait times. Some commentators
after-hours care available in communities
attribute increased wait times to the lack of
that in
general
(Canadian Doctors for Medicare, 2013). The
were non-urgent or for non-emergency
2010, about half of emergency room visits
of Ontario, 2010).
problems (Office of the Auditor General
Ontario auditor
The
most
frequent
recommendation
notes
medicare
among those who support
(Priest, Rachlis, & Cohen, 2007;
money into the system
Doctors for Medicare, 2013),
Canadian Health Coalition, 2009; Canadian
is
not
putting
more
This
include centralized
deploying existing resources more efficiently.
doctors working in groups
intake of patients, using interdisciplinary teams, and
other suggestions
rather than on their own to address patient needs, among
frear
Another solution is to provide more after-hours primary care clinics to
to
This would free up emergency departments
non-emergency patient needs.
but
can
handle medical emergencies.
THE CANADIAN HEALTH SCENE IN
INTERNATIONAL PERSPECTIVE
In this section,
a
some
health policy are placed within
include some demograph. data,
indicators of Canadian
Thes
comparative perspective.
measures
Overview of
the
Canadian
Health Care
System
183
atorS of the health status of Canadians, and health care system functionino
Canada is often compared with the UK, the US, and Sweden. The US provides
an exemplar of comparison with a market-driven approach to health policy,
while the UK has a somewhat similar system to Canada, albeit with a separate,
whilet
aelv oriented system. Sweden represents a good example ofa state-oriented
social democratic approach to health policy governance, although the country
has experienced some ratcheting back of its welfare system in recent years.
Demographics
these four nations on a per capita gross domestic
The US is the wealthiest of
GDP for the US in 2014 was USD
product basis (Table 6.1). Per capita
nations
S46,405.26, which is rather more than for the other three comparison
economic growth from the 1990 to
(Trading Economics, 2015). In terms of
nations showed rather similar rates of
2005 and 2010 to 2014 periods, all
in the degree of
annual change in GDP. Striking differences are seen, however,
coefficient (OECD, 2014). The UJS
as measured by the Gini
income
inequality
the least.
shows the greatest income inequality, and Sweden
over the age of 65 years (a
Finaly, in terms of the percentage of the population
Sweden shows the highest proporgood indicator of the aging of the population),
near the low end on population
tion, and the US the lowest. Canada is currently
calculates aging support projections (OECD,
aging at 14 percent. The OECD
number of those who can prorate correlates with the
The
old-age support
2014).
reli-
the number of older people who may materialy
that the number of people who are
ant on support from others. Its analysis suggests
next 40
the elderly will decline over the
are able to support
who
and
non-clderly
be
vide economic support to
years in most countries.
Canadas
(CIHI) reported that
The Canadian Institute for Health Information
Canadian, up by
billion in 2014, or $6,045 per
$214.9
be
would
spending
in healch spending
rate of growth
d61 per person from 2013 (CIHI, 2014). The
health
growth together. Overall,
population
and
infation
S2.I
than
percentless
between 2010 and
per year
an average 0.4 percent
in
fell
health
by
approximately 11
e a l t h spending represented
Canada
spEnding
percent
of Canadas GDP
in
a04. Most spending is on hospitals, drugs, and physicians.
health
driver of rising
not a major
is
population
the aging
"modest
bn8'y,
cost
aging as a
Costs (CIHI, 2014). CIHI describes population
the
tact,
c
In
2014, p. 13).
(CIHI,
percent per year"
has seen
CStmated
n
a l
at 0.9
of public-sector
change, from 44.6
health dollars
percent
spent
in 2002
to
on
Canadian seniors
45.2 percent in
2012.
Health Policy in
184
Canada
Among OECD countries, trends in the growth of total hcalth expenditse.
have been identified since 1975 (OECD, 2014). The period between 1
and 1991 was one of growth in health expenditures; berween 1991 and 190
governments cut health spending as they contended with fiscal deficits:
and
finally, 1996 to 2011 was a growth period of about 4 percent per year. Durin
ing
this last phase, health care became a priority for anadians (OECD, 2014
This was the period during which the federal, provincial, and territorial
governments signed the 2003 and 2004 health accords. As noted earlier in the
chapter, these accords increased spending on human health resources, drugs,
ags,
hospitals, and advanced diagnostics.
Health Status
Among the four countries compared, life expectancy is the greatest in Sweden
and the lowest in the US (Table 6.2). Consistent with this pattern, the US
shows the greatest number of premature years of life lost (prior to age 70) and
Sweden the lowest. A similar pattern is seen for infant mortality and low birth
weight rates. And, not surprisingly, this same pattern holds for obesity rates,
where Sweden's rate of 11 percent is strikingly lower than the 36.5 percent
seen in the US.
Table 6.2: Health Status in Canada and Three Comparison
Nations, 2011
Canada
United
States
Life expectancy
United
Sweden
Kingdom
81.0
78.7
81.1
81.9
Males
4,168
6,133
3,988
1,916
Females
3,555
2,479
3,081
Infant mortality/1,000
2,554
4.9
6.1
4.3
2.1
Obesity %
25.4
36.5
24.8
11
Premature years of life
lost/100,000 (2009)
Source:
Organisation
Paris: OECD
for
Economic
Co-operation
and
Development. (2013). Health
ar
u
lance.
s
Overview
of the
dian
Canag
Health Care System
185
Usage of the Health Care
ble 6.3:
able
Comparison
Nations, 2017
Canada
System in Canada and Three
United
United
States
Kingdom
2.6
2.6
2.8
4.0
9.5
11.1
8.2
11.2
1.73
2.48
2.3
2.0
89
64.4
84.3
MRIs/1,000,000
8.5
35.5
5.9
Hospital discharges
83
125
129
163
Physician consultations
7.7
4.0
2.9
(2010)
(200)
5.0
(2009)
Physicians/1,000
Nurses/1,000
Acute care hospital
Sweden
beds/1,000
Occupancy rate of
acute care beds (%)
per capita
Source: Organisation for Economic
Health at a glance:
Co-operation and Development. (2017).
OECD indicators. Paris: OECD.
Usage of the Health
Table 6.3
countries.
provides
Care
System
Sweden has the
highest
four
systems in the
available to the
number of physicians
The US has the highest
data about the health
care
lowest (2.6).
population, while Canada has the
Of interest is the high
number of acute care beds in hospitals (2.48).
million
use in the US (35.5 per
for
available
machines
number of MRI
rate
for
acute
care
beds
1s
people). In 2013, Canada's high occupancy
consultations.
of physician
number
irrored in its having the highest
ne
discharges among
of
hospital
rate
lowest
the
Lanada, however, has
nations compared.
Health Expenditures
dollars s
res
on
health
on a
per
equivalent US
capita basis in
from $6,401
presented in Table 6.4. The US spends, o n
average,
$8,508, up
n
Sweden
2005
than the UKand
a n a d a and the US spend more
In
absolute
an absoIutc
on an
on
Health Policy in
186
Council's Demise
Health
6.5:
Box
Canada
"Just Made Sense"
Spokesman Says
federal-provincial
As the 2004
independent body
health accord
expires, so will thhe
monitoring it
CBC News
for the Health Council of
winding down the funding
tor monitoring the results of the
Canada, the independent body responsible
health accord struck in 2004. But with the $41 billion desl
Health Canada is
federal-provincial
set to expire in 2014, a spokesman for Health Minister Leona Aglukkaq savs
work "just made sense."
wrapping up the council's
Steve Outhouse says the Health Council measured results in the health care
system across Canada, work already being done by the Canadian Institute for
Health Information (CIHD).
He says Aglukkaq has already announced it will be renewingg and expanding
funding for CIHI.
The minister's spokesman said it is possible for the provinces to take over the
council and "keep it going" But although the offer has been made, so far there
has been no interest from them, and no complaints, says Outhouse.
Duncil's chief executive. John Abbot, said Health Canada told him
last week that its $6.5 million
funding would continue through this fiscal year,
but come to an end after that, with $4 million to lose
up shop in 2014)
The council relies entirely on federal
money to fund its operations. Abbott
said the "federal fiscal environment" was
cited in the
offered to
him for the decision. "This did
come
explanation
right out of the blue," Abbott told lhe
Canadian Press on Tuesday.
Federal spending to focus
on
'front-line' services
Outhouse said the federal governmentis instead
focusing its heal
spending "on patient-oriented research,
things that are connectea
front-line health-care service to
Canadians, including transfers that go
provinces and territories."
It seemed like a
natural time
When the current
make that
accord expires next transition," he explained.
will
year, the federal
continue to increase its
health
government
transfers
to the
at a lower rate
of increase,
provinces for 2014 to 0 , but
and with no
strings
rings attached. Finance
Finance Minister
Ministc Jim
to
Health Policy in
186
Canad
nada
Box 6.5: Health Council's Demise "Just Made Sense,"
Spokesman Says
As the 2004
federal-provincial health accord expires, so will the
independent body monitoring
it
CBC News
Health Canada is winding down the funding for the Health Counc
Canada, the independent body responsible for monitoring the results of th
federal-provincial health accord struck in 2004. But with the $41 billion da
set to
expire
in
2014,
a
spokesman for
Health Minister Leona
Aglukkaa
save
wrapping up the council's work "just made sense."
Steve Outhouse says the Health Council measured results in the health
care
system across Canada, work already being done by the Canadian Institute for
Health Information (CIH).
He says Aglukkaq has already announced it will be
renewing and expanding
funding for CIHI.
The ministers spokesman said it is possible for the provinces to take over the
council and "keep it going" But although the offer has been made, so far there
has been no interest from them, and no complaints, says Outhouse.
The council's chief executive, John Abbott, said Health Canada told him
last week that its $6.5 million funding would continue through this fiscal year,
but come to an end after that, with $4 million to close up shop in 2014-15.
The council relies entirely on federal money to fund its operations. Abbott
said the "federal fiscal environment' was cited in the explanation offered to
him for the decision. "This did come right out of the blue" Abbott told The
Canadian Press on Tuesday.
Federal spending to focus on front-line' services
Outhouse said the federal government is instead focusing its healtn
spending "on patient-oriented research, things that are connected
front-line health-care service to Canadians, including transfers that go
provinces and territories."
"It seemed like a natural time to make that transition," he explained.
When the current accord expires next year, the federal government will
continue to increase its health transfers to the provinces for 2014 to 2024
at a lower rate of increase, and with no strings attached. Finance Minister
ut
Canadian
Health
Care
System
187
e
Overview ofthe
abrupty
Flaherty
take-it-or-leave-it
unveiled a
plan at a meeting of provincial and
in Dec. 2011. He committed to a six per cent annual
finance ministers
erritorial
each of the first three years. After that, annual increases will
in funding for
increase
c e n t - o r more, if the economy is strong.
of three per
he a minimum
this month to provincial health ministers, who also act
terri
In
a
letter sent earlier
members of the council,
Aglukkaq said it is up to the provinces
whether to keep funding the organization. "I should
to decide
territories
and
about federal funding for the council, and that
that this is a decision
e
corDOtate
emphasize
formal
decisions about its
be made collectively
future as an entity will need to
Aglukkaq wrote.
work of the
to follow on from the
council's corporate members,
by us, the
The council
was
formed
Commission and focus
on
and accountability
both performance monitoring
work for helping
care system. Some credit its
in the health
in the public health
times and encouraging innovation
access
is
lower wait
system
to
ensure
across regions and age groups.
For
the current accord expires.
said he sees a role for the council after
there will still
instance, he noted,
health-care
at
accountable
were
public could certainly
to
can u s e those reports
they
and national level."
at the provincial
play
accountable
be a need to hold governments
written
so
reports
of
delivery and spending. "Most our
better
understanding of the
have a
that the Canadian
issues
care
to
maintained
Abbott
for
Romanow
and that
National standards at risk?
help
hold governments
Association, saidd
Medical
of the Canadian
Dr. Anna Reid, the president
needs all the
care system
health
"Canada's
in a news release Tuesday that
few bodies
one of the
lose
to
about
instead we are
Information it can get, but
the health
toward ensuring
progress
measuring
sponsible for monitoring and
needs of Canadians.
Care system is able to meet the
where the
to pick up
provinces
the
Coalition urged
he
Canadian Health
Tederal government is
work continues.
leaving off so the
the provincial
Canadians and
Onalsurveys consistently
show that
McBane,
Michael
leadership," said
federal
1s
want
"Instead Harper
erritorial governments
release.
coordinator in another
between his
distance
Calition's national
and then put
choosing to cu
a n d
run-cut
the funding
government and universal health care."
Universal health
perating
in
Canada is
about
to
fragment
into 14
separate
federal governme.
other. The
each
from
independentlyv
care
Health Policy in Canad-
188
is running away from its essential role as guardian of national standards
and universal access to care for all Canadians regardless ot where they live
said McBane.
The left-leaning Council of Canadians called the funding decision 'scandalous
The Council of Canadians views this as an intentional and very serious
attack on the public health-care system in Canada and a clear indication that
the federal government is not interested in the health of Canadians," Adrienne
Silnicki, the group's health-care spokeswoman, said in a statement.
Canadian Doctors for Medicare also criticized the move. "The federal
government is no longer walking away from health care, it's sprinting at
full speed," Dr. Ryan Meili, the group's vice-chairman, said in a statement.
"Cutting funding to the Health Council means cutting information on
sustainability, quality and efficiency of our health care system-information
that Canadians should be able to expect from their government."
NDP health critic Libby Davies said there remains a role for the council, so
cuting its funding is a mistake. "It's a lack of planning and a lack of foresight
at minimum, and at worst, it's another indication that the federal government
is abandoning its role in health care," she said.
"So I think either way you look at it, it's bad news."
Source: Health Council's demise "just made sense," spokesman says. (2013, April 17). CBC
Neus. With files from Amanda Pfeffer, The Canadian Press. Retrieved from www.cbc.ca.
dollar basis. US expenditures represent almost 20
percent of its GD. HOwevc
Canada ranks sixth highest among the 30 OECD nations for whom data s
available. Of note is that of
out 70
$4,522
Canadas
per capita expenditures, about
$3,183-is
from
percent-or
publicly financed. Annual growh in
spending
2000 to 2011 was only 3.25 percent in
Canada.
Per
capita spending on pharmaceuticals is
highest in the US 985).
Canada's spending on pharmaceuticals is
USD $701, compared to
$443 in Sweden. In terms of average
growth in health expenditur
2000 to 2009, the UJK had the
USD
from
three nations.
highest growth rate Compared
cor
to
the
other
Overview of the Canadian Health Care System
Table 6.4: Health
Nations
189
Expenditures in Canada and Three Comparison
Total per capita
expenditures (USD)
Public per capita
expenditures (USD)
Total expenditures as %
Canada
United
United
$4,522
States
$8,508
Kingdom
$3,405
$3,925
$3,183
$4,066
$2,821
$3,204
11.2
17.7
9.4
9.5
68.5
47.8
82.8
81.6
0.8
1.3
-1.8
1.8
$701
$985
$443
-0.3
-0.5
-0.9
7.4
4.1
Sweden
of GDP
Percentage ofexpenditures
that are public
Average annual growth
in health expenditures
2009-2011 (%)
Per capita pharmaceutical
expenditures (USD)
Average annual growth
in pharmaceutical
expenditures 2000-2011
(%)
Physician consultations
5.0
3.0
per capita
ource:
Health at a glance 2013:
Organisation for Economic Co-operation and Development. (2013).
OFCD health indicators. Paris: OECD.
Public Share of Health
Spending
in the US is
health care spending
rpriSingly, only 47.8 percent of
while
years, and
rate of 70 percent is stable from previous
anadas
lower than the UK (82.80)
cably higher than is the case in the US, it is
lowest
is among the
coverage
public
Canada's
n(81.6%). Indeed,
oof OECD nations.
Policy in
Health
190
Canada
SUMMARY
Canada
While wealthier than Sweden, Canada shows greater income inequality.
rals
seen in the U,
provides a health status profile that, while superior to that
life expectancy, infant
well behind what is seen in Sweden. This is the case for
rate.
low birth weight rate, and obesity
mortality, premature years of life lost,
Sweden's on an absolute basis
Canada's health care system spends more than
in Canada, much less of that spending
and also as a percentage of GDP Also,
is
health costs in Canada,
in Sweden. The growth in
than
provided
nations. Canada provides
less than that scen in the other comparison
publicly
however, is
show very high occupancy. Finally
hospital beds, and these
and
available than the other countries,
fewer
physicians
Canada has significantly
number of
indicated by the average
to be very busy, as
these physicians appear
is a problem in rural and
practitioners
of
general
consultations. The shortage
such as Toronto.
urban
in
also
and
large
remote communities,
at a
fewer
acute care
centres
care system is operating
that Canada's health
sugeest
findings
more than
nations. Despite spending
is the case in other
than
higher capacity
of GDR, health status
and
percentage
dollars
absolute
Sweden on health care in
of these health
nation. The s o u r c e s
that
in
s
e
e
n
those
indicators fall behind
to these
health care system c a n respond
the
which
m
e
a
n
s
the
by
These
differences
and
challenges are
taken up in later chapters.
CONCLUSIONS
services
and delivery of health care
described the organization
has
This chapter
health care and the
chronicled the history of public
also
has
valued
in Canada. It
Medicare is Canada's most
federalism in
shaping it.
health spending in Canada and comparison
systems
are m o r e cost-eficient than private
role of Canadian
of
social program. A comparison
nations shows
that
shaped health
care
public systems
of citizens.
the health needs
and better s e r v e
conflict have
and ongoing federal-provincial
Canadian federalism
to the
kederalism, among other dynamics, led
in Canada.
single-payer
system
intergovernmental
the
to
system
ensure
that
health care. The ongoing
characterizes anadian
to diSCussions about how to sustain
conflict has
contributed
not always
into the future,
its sustainability.
Canada
provides
Comparatively,
Sweden.
well behind
the US, falls
With a
a
view
health
to
strengthening the system
proile that, while
Canadas health care
system
saunerior to
pends
nore
191
Overview of the Canadian Health Care System
show for it. The system appears to be operating
and has more average
capacity and with fewer physicians,
than three other comparison nations. The sources of these
than Sweden with rather less
at
very
high
consultations
indicators
are
to
examined in later
chapters.
APPENDIX 6.1: A DETAILED HISTORY OF CANADA'S
HEALTH CARE SYSTEM
1867
British North American Act passed: federal government
responsible for marine hospitals and quarantine; provinciall
territorial governments responsible tor hospitals, asylums,
charities, and charitable institutions.
1897-1919
Federal Department of Agriculture handles federal health
responsibilities until Sept. 1, 1919, when first
Department of Health created.
1920s
established
Municipal hospital plans
federal
Manitoba,
in
Saskatchewan, and Alberta.
1921
1936
1940
1942
Royal Commission on Health Insurance,
British Columbia.
insurance
health
British Columbia and Alberta pass
legislation, but without an operating program.
Health created.
Federal Dominion Council of
Committee
Federal Interdepartmental
Advisory
on
Health
Insurance created.
1947
Saskatchewan initiates
insurance
1948
universal
National Health Grants
to
Program, federal; provides grants
territories to support
health-related initiatives,
training,
public health, professional
research.
and public health
provincial surveys,
British
Columbia
including hospital
insurance
plan.
construction,
creates
limited
Newfoundland
joins
provincial hospital
Canada; has
hospital insurance plan.
1950
Alberta
creates
limited
provincial hospital
July 1.
1957
public hospital
plan, January 1.
provinces and
1949
provincial
Hospital
Insurance and Diagnostic
proclaimed
a
cottage
insurance
Services
Act,
plan,
federal,
50/50 cost
provides
1;
(Royal Assent) May
insurance plans,
sharing for provincial
in force July 1, 1958.
and territorial hospital
Health
192
Policy in Canada
Manitoba, Newfoundland, Alberta, and
British Columbia
Col
and British
1958
create
1.
hospital
plans
with federal cost
insurance
hospital
cost sharing, July 1.
Saskatchewan
federal
1959
insurance
sharineL
ing, July
plan brought in
nder
Ontario, New Brunswick, and Nova Scotia create hoci
insurance
plans with
federal
cost
sharing. January
1.
rince
Edward Island creates hospital insurance plan with federal
cost sharing, October 1.
1960
Northwest Territories creates hospital insurance plan with
federal cost sharing, April 1. Yukon creates hospital insurance
plan with federal cost sharing. July 1.
1961
Quebec creates hospital insurance plan with federal Cos
sharing, January 1. Federal government creates Royal
Commission on Health Services to study need for health
insurance and health services; appoints Emmett M. Hall
as Chair.
1962
Saskatchewan creates medical insurance plan for physicians'
services, July 1; doctors in province strike for 23 days.
1964
Royal Commission on Health Services, federal, reports
1965
1966
recommends national health care program.
British Columbia creates provincial medical plan.
Canada Assistance Plan (CAP), federal, introduced; provides
cost sharing for social services, including health care not
covered under hospital plans, for those in need, Royal Assent
July, effective April 1. Medical Care Act, federal, proclaimed
(Royal Assent), December 19; provides 50/50 cost sharing
for
vincial/territorial medical insurance plans, in force
July 1, 1968.
1968
Saskatchewan and British Columbia create medical insurance
plans with federal cost sharing, July 1.
1969
Newfoundland, Nova Scotia, and Manitoba create medical
insurance plans with federal cost
sharing, April 1. Alberta
creates medical insurance plan with
federal cost sharing, July
1. Ontario creates medical insurance
plan with federal cost
sharing, October 1.
1970
Quebec
creates medical
sharing, November
insurance
plan
insurance
1. Prince
with federal
plan
with
federal
cost
Edward Island creates medical
sharing, December 1.
cost
Overview
1971
1972
1977
1979
of the Canadian
Health Care
System
193
New Brunswick creates medical insurance plan with federal
cost sharing, January 1. Northwest Territories creates medical
insurance plan with federal cost sharing, April 1.
Yukon creates medical insurance plan with federal cost
sharing, April 1.
Federal-Provincial Fiscal Arrangements and Established
Programs Financing Act (EPF) federal cost-sharing shits to
block funding.
Federal government creates Health Services Review; Emmett
M. Hall appointed Special Commissioner to re-evaluate
1980
publicly funded health care system.
Health Services Review report released August 29;
recommends ending user fees, extra billing, setting national
standards.
1982
Provincial/territorial reciprocal billing agreement for inpatient hospital services provided out-of-province/territory.
Federal EPF amended; revenue guarantee removed, funding
1983
formula amended.
Royal Commission on Hospital and Nursing Home Costs,
1981
Newfoundland, begins April, reports February 1984. Comite
d'étude sur la promotion de la santé, Quebec, begins, ends
1984. La Commission d'énquête sur les services de santé et les
services sociaux, Quebec, begins January, reports December
1987. Federal Task Force on the Allocation of Health Care
Resources begins June, reports 1984.
1984
The Canada Health Act, federal, passes (Royal Assent April
hospital and medical acts; sets conditions
and criteria on portability, accessibility, universality,
fees
comprehensiveness, public administration; bans user
17),
combines
and extra billing.
Provincial/territorial reciprocal billing agreement for out-
1985
patient hospital services provided out-of-province/territory
Health Services Review Committee, Manitoba, begins,
reports November.
1986
Federal transfer payments
rate
of growth reduced.
Health Review Panel, Ontario, begins November, reports
1987
June 1987.
remier's
in 1991.
Council
on
Health
ends
Strategy, Ontario, begins,
194
Healh
Koyal Commission on
Health Care, Nova Scotta, DEFls
August 25, reports Decemlber
On
the
1'lie y in
Committee
1989, Advisory
Utilization of Medical Services,
cptembcr, reports Septemlber
Alberta,
bepins
1989. All provinces and
territorics in compliance with the Canada Flealth Acu by
April 1.
1988
P'rovincial/territorial governments (except Quebec) sign
reciprocal billing agreement for physicians' services provided
out-of-province/territory. Commission on Directionsin
Health Care, Saskatchewan, begins July I, reports March
1990. Premier's Commission on Future Health Carc for
Albertans, Alberta, begins December, reports December
1989. Commission on Selected Health Care Programs, New
runswick, begins November, reports June 1989.
1989-1994
Further reductions in federal transfer payments.
1990
Royal Commission on Health Care and Costs, British
Columbia, begins, reports 1991.
1991
1994
National Task Force on Health Information, federal, reports;
leads to creation of Canadian Institute of Health Information.
Task Force on Health, Prince Edward Island, begins June,
reports March 1992.
National Forum on Health, federal, created to discuss
health care with Canadians and recommend reforms,
begins
October, reports 1997.
1995
Federal EPF and CAP merged into block funding under
the Canada Health and Social Transfer
(CHST), to support
health care, post-secondary education, and social services.
1996
Federal CHST transfers begin
April 1.
Health Services Review, New Brunswick,
begins, reports
February 1999.
Social Union Framework
Agreement (SUFA) in force:
federal, provincial, and territorial
governments
Quebec) agree to collective approach to social (excep
policy and
program development, including health.
Minister's Forum
on
and Social
1998
1999
Health
Services, Northwest Territories,
begins
July, reports January 2000.
2000
ministers Communiqué on
announced
announced
September 11. Commission of StudyHealth,
on
Health and
Social Services (Clair Commission),
Quebec, created June
First
Canadian
ofthe
Health
Care
System
195
O v e r v i e w
15, reports December 18. Saskatchewan Commission on
Medicare (Fyke Commission), Saskatchewan, begins June
14, reports April 11, 2001. Premier's Advisory Council
on Health for Alberta (Mazankowski Council), Alberta,
established January 31, reports January 8, 2002. Premier's
Health Quality Council, New Brunswick, begins January
reports January 22, 2002.
Standing Senate Committee on Social Affairs, Science, and
Technology review (Kirby Committee), federal, begins March
2001
1, publishes recommendations October 2002. Commission
on the Future of Health Care in Canada (Romanow
Commission), federal, begins April 4, reports November
2002. British Columbia Select Standing Committee on
Health
(Roddick Committee), begins August, reports
December 10. Northwest Territories Action Plan, begins
Consultation
November, reports January 2002. [Health]
released January 21,
Process, Ontario, begins July, results
Discussion
2002. Health Choices-A Public
on
the Future
of Manitoba's Public Health Care Services, Manitoba, begins
January, reports December.
Care Renewal, announced
First ministers Accord on Health
established to monitor
February 5. Health Council of Canada
Accord reforms, December 9.
and report on progress of
transfers: the Canada Health
Federal CHST split into two
Social Transfer (CST), April
Transfer (CHT) and the Canada
Care,
Plan to Strengthen Health
1. First ministers A 10-Year
2003
2004
September 16.
Source.
http://www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/2011-hcs-sss/index-eng.php#al5.
NOTE
for a full treatment
introduction (1996)
Canadian democracy: An
Brooks's
relations and puDilc
phen
intergovernmental
for
implications
nadian federalism and its
olicy at the federal and provincial levels.
Health Policy in Canada
196
CRITICAL THINKING QUESTIONS
1.
How can Canadian federalism
2.
of medicare in Canada?
Why might the medical
3.
contribute
constructively to the preservation
protession support the preservation of medicar
increased private involvement
Why might the medical profession support
in the health care system?
possible programs could you envisage
care system?
publicly organized health
4.
What
5
How
can
the allied health professions
occupational therapy)
become
engaged
(e.g
in
as
becoming
part of the
nursing, physiotherapy
helping
to
maintain
a
public
health care system?
FURTHER READINGS
Armstrong, P. (2010). Wasting away:
Press.
Canadian health care. Toronto: Oxford University
Armstrong, H.,
&
The
undermining of
referred to as Canadas best-loved
system is often
in
the most accessible health care systems
social program. It has been one of
role in prolonging the lives of many
the world and has played a significant
under attack from a variety of
Canadians. This book examines how it has come
Canada's health
care
sources and the effects these attacks have had on the system.
Carroll, A.E. (2012,
Ihe
April 16). 5 myths about Canada's health care system:
Real Posibilitis.
truth may surprise you about international health care. AARP
Available online at www.pnhp.org.
American
This article discusses the difterenee berween the Canadian and
and the
health care systems. Among issues cxamined are wait times in Canada
proportion of Canadians who travel to the US for medical care.
Rachlis, M. (2004). Preseription for ewellenee: Hou innorvation is satins
Camadas health care system. Toronter HarperC ollins, Available online at ww
michaelrachlis.com.
In his latest book. Michael Kachlis argues that the eure tor (anadas health
delivery system is not more moncy anu not Ptivatization; he savs the answer
Can be found in the system INei.
Tic ucstibes various innovations and best
ices across the system that have impYed health dclivers and enhancoi
qualiry
for the patients and
hcalth protessinals
Chapter 7
CARE
HEALTH1
EFORM IN CANADA
INTRODUCTION
From the 1980s to the mid-2000s, Canadian governments were preoccupied
with issues related to the health care system and how to reform it. The penchant
for reform has been driven by concerns that medicare is inctficient and overly
cosuly as it is currently organized. This has fuclled support for allowing a parallel
private system to develop to ease pressure on the public system. For example,
perceptions of long wait times tor specialist care and the non-responsiveness of
the health care system to emerging issues have been used to build support for
radically overhauling the system. Some critics have proposed privatizing some
health care services and allowing private for-profit health care organizations to
provide care.
Between 2000 and 2004, several major rcports on health care reform
were issued. These included the Mazankowski Report, prepared for the
Government of Alberta; the Romanow Royal Commission on Health Cares
the Kirby Report from the Canadian Senate; the Fyke Commission on
Miedicare in Saskatchewan; and the Clair Commission on the Study of Health
and Social Services in
e
et
les services
Quebec (Clair Commission d'etude sur les services de
sociaux, 2001; Commission
on
Medicare, 2001; Kirby,
2002; Mazankowski, 2001; Romanow, 2002). Each report proposes a course
o action for reforming medicare. The (Mazankowski, Kirby, and Romanow
and
be the most infuential. Their key recommendations
reforms that
C retorms are the focus of this chapter. Hecalth issues and other
C
emerged since the early 2000s are also examined. commitment to tne
tne authors of the major reports express their
on medicare
of medicare, but differ sharply in their perspectives
tity
an
andhow
can be repaired. Stone's distinction between thepolis and the market
PrESproved
to
sustainability of
can help to elucidate the varying concepts ofsociety that inform the orientation
201
1988).
ol these eports ad
heir
1ecommendations
standing it t
(Stoe,
Inelir the
bes accomplisheel
peration of the heallh care nystem
Mciety 1
be a connmnal cflort ndertaken by
care
health
syste
whole? Or is it Ibest to allw the
inliviclu.l interei
driven
by
markeplace
Dypriniples of the
A
FRAMEWORK
(THE
FOR
the flii
mm.
e
povened
REFORM
MAZANKOWSKIREPORT)
wlo chaircd the Prenicr
afier Don Mazankowski,
named
This report
Alberta. Mazankowski is best known for bcin
Council on Relorm in
was
Advisory
Minister
of
linance in Brian Mulroney's
Conservative
governiment in
Ottawa
for fundamental changes in howhealth
1980s. His 2001 report calls
o ensure their long-term sustainability
services are financed and delivered
the broader determinants
an extensive section on
during the
care
(Mazankowski, 2001). Despite
subsequently ignored (Raphacl,
of health, most of which the Alberta government
have garnered virtually all health
2003), the sections on the health care system
"ensure sustainability of the
attention. Mazankowski's primary goal is to
policy
5).
health system for years to come" (Mazankowski, 2001, p.
was never intended
First, Mazankowski contends that medicare
provide
the full range of health services, treatments, drugs, and technology. Criticizing
Mazankowski
the current system as an "unregulated monopoly" (2001, p. 4),
and
to
choice for
greater
larger role for the private sectorin health care
recommendations
consumers. He argues that the primary purpose of the report's
advocates
a
is to stimulate innovation. Specific mechanisms include more direct payments
from citizens for health care services, such as user fes, premiums, deductibles,
and taxes for use of the system. One of his key recommendations was the
creation of medical savings accounts (MSAs).
Medical Savings Accounts
MSAs are health accounts formed in conjunction with high-deductible health
insurance-that is,
the
policy pays
a
significant
portion of initial costs-that
can be set up by individuals, employers, or governments (Ramsay, 1998). As an
illustration, employers would set up MSAs for their
employees. A portion of these
funds would be used to purchase health care
for those employees. When
these funds were used up, employees would
assume full responsibility tor
Health Care
Reform
in Canada
203
paying for their medical care up to a designated cap, at which catastrophic
insurance
would be
provided.
Mazankowski argues that MSAs would be more cost-efficient than
raditional insurance policies. It is claimed that MSAs foster "more prudent"
enending of health care dollars without harming the health of individuals
Ramsay, 1998, p. 3). Rules governing MSA plans could vary with respect
ta how surplus funds in personal accounts can be used once coverage periods
end. In theory, MSAs would reduce demand for services by making individuals
Anancially responsible for their consumption of health services (Short, 2002).
Mazankowski argues that MSAs and other co-payment strategies would
discourage inappropriate use of health care services, and also "give people more
control over their health care spending (Mazankowski, 2001, p. 17). He ses
these reforms as increasing personal choices in health care services, thereby
more competition and increased accountability for health care
enabling
services organization and delivery. He recommends delisting-or removing
now be
from public health care system coverage-some services that would
our
for privately, arguing that "private innovators could do wonders for
paid
health care system" (Mazankowski, 2001, p. 27).
health care
Further, Mazankowski recommends that private, for-profit
facilities receive public financing. He also calls forincreased development.of
public-private partnerships (P3s)
services. A P3 is
private
sector to
an
to
build
arrangement in which
finance, develop,
hospitals
a
construct,
and
provide
health
care
with the
government contracts
infrastructure
own, and operate
such
as
make it available
to
key aspect of P3 arrangements
is that, following
those already initiated by Canadian provincial governments
or other public building,
the construction of a facility such as a new hospital
and
public service (Savas, 2005).
The
would own it and
private corporation that built it
basis..
health care authorities on a lease-back or rental
the
Regional Health Authorities
role
recommendations is a larger
Mazankowski's
of
ther important aspect
would work with
care. RHAs
health
in
egional health aurhorities (RHAs)
service agreements
her regions
to provide health services and also develop facilities. "These
gions to
of
not-for-profit health
private
consider identifying specific
would
Cements
ange
or
COlaborations
Swith
hospitals,
providers
areas
or
of specializatiOn.
direct
administration,
would provide "ijoint
ownership arrangements
and alternative
nd
204
Health
1olicy in
(anada
payment mechanisms" (Mazankowski, 2001, p. 50). Authorities would De
authorized to raise revenues by charging fces for a range of services that woud
include instituting co-payments for long-term care and home care, restaurant
inspections, environmental assessments, and public health education programs.
since their
Acknowledging that RHAs have faced numerous challenges
in Alberta in 1995, Mazankowski believes that his recommendations
inception
will address many of these problems (Mazankowski, 2001).
Health Care Guarantee
Mazankowski recommends health care guarantees to reduce wait times for
and other specialized health care services (Mazankowski, 2001).
specialists
Health care guarantees are predetermined wait-time deadlines for various
these would be to ensure timely access
medical procedures. The purpose of
be assured access to needed health
where the individual resides would be
services within 90 days, the RHA
services to be provided by either a public or private
required to arrange for those
costs of the service
costs for the patient and the
sector provider. The travel
resides. The
to the region in which the patient
would be
to care.
Specifically, it Albertans
charged
provision
as a mcans
of
not
the federal
by
guarantees has been
reducing wait times for various medical procedures
health
concept of provincial
government
could
care
endorsed
and treatments (see Box 7.1).
Box 7.1: Why Ontario Keeps Sending Patients South
By Lisa Priest
The Globe and Mail
More than 400 Canadians in the full throes of a heart attack or other cardiac
emergency have been sent to the United States because no hospital can provide
the lifesaving care they require here.
Most of the heart patients who have been sent south since 2003 typically
show up in Ontario hospitals, where they are given clot-busting drugs. Ifthose
drugs fail to open their clogged arteries, the scramble to locate angioplasty in
the United States begins.
"They rushed me over to Detroit, did the whole closing of the tunnel,
said Eric Bialkowski, 47, of the heart attack he had on March 14, 2007, in
Windsor, Ont. "It was like Disneyworld customer service."
Reform
Health
in Canada
205
Care
W/hile other provinces
has sent
have sent
women
75 pregnant
patients out of country-British Columbia
or
their babies to
Washington
State since
2007-nowhere is the problem as acute as in Ontario.
February,
Ar least 188 neurosurgery patients and 421 emergency cardiac patients have
heen sent to the United States from Ontario since the 2003-2004 fiscal year
ro Feb. 21 this year. Add to that 25 women with high-risk pregnancies
2007.
south of the border in
Although Queen's Park says it is ensuring patients receive emergency care
Conservative health critic Elizabeth Witmer
when they need it, Progressive
says it reflects poor planning.
That is particularly the case with neurosurgery,
she said, noting that four
have predicted a looming shortage.
reports since 2003
outside for care-irs
"This province and the number of people going
Witmer said.
increasing in every area," Ms.
"I definitely believe that it is
meet
the demand, but
we
don't
even
officer, said 30 per
assisted
living centres, a
president and chief
hospital medical beds are
such
more
own homes with proper home-care supports.
That squeezes the system at
Condition
improves
patients cant
get
cannot
bed
a
at
to
appropriate placements,
rehabilitation facility or even their
nursing home, a
currently occupied by patients awaiting
as
unable
Association's
of Ontario's
cent
simply
Were
know what the demand is."
Hospital
Tom Closson, the Ontario
executive
planning...
very bad
intensive care units
both ends: Patients in
whose
units, and some emergency
get into step-down
is jam-packed
he said, adding that "everything
all,
at the moment.
health services required
mix ofbeds and
for determining the right
not been
that that task has
noting
he
said,
needs to be developed,
Amethod
in
Ontario
undertaken
on a
provincial basis for
Osthield,
Laurel
therman,
press
said that
secretary
a
preferable
Ot
when
a
for
provincial
to
in emergencies,
clinical decision.
1s
decade.
with
someone
few kilometres
away,
demand has peaked,
a
Health
Minister
where the patient goes
in
heart attack
rather than
government
on a
Windsor to
long ride to
has responded,
the problem
and
becomes a
be
sent to
lLondon, Ont.
struck
she said. lt
$4.1l-million
pancl to study
patients.
neurosurgery
c r e a t e d in
the tide of US
George
has beer
een
a neurosurgery expert
provided to stem
services
As well, stand-alone
gioplasty
were
or in May.
Windsor
Health Policy in Canada
206
Canadian
Medical
Ontario
speak about the
Organisation
Association
problem, but
Economic
for
president
Development
Co-operation and
patientsand often
a financial drain.
We
the
keep coming back to
same root
cause," Dr.
Jennifer Walmsley went
in October and
was
aneurysm. That
Ontario
hospital
not
problem when they
to
in
Day said
a
the
finance
to
doctors-are sometimes
health system is
interview from Ottawa. "The
Patients first learn of the
couldn't
he
said
is the last in
noted this country
hospitals with global budgets.
Under that model,
Day
Brian
viewed
as
telephone
consumer-focused."
are
critically ill.
Orangeville
to a ruptured
Centre in
Headwaters Health Care
diagnosed with a
hospital
acute-care
cerebral hemorrhage due
does
have neurosurgery and
not
that does could take her. She
was
then rushed
to a
no
Buffalo
hospital.
Headwarer's chief of staff, Jeff McKinnon, said three neurosurgery patients
have been
sent to
Buffalo in the past year. Others have gone
to
Toronto,
Mississauga, Hamilton and London.
Headwaters has an arrangement with
Radiologist Louise Keevil said
Ontario hospitals to send electronic images for their
neurosurgeons at other
assessment, but "the limiting factor is availability of beds in their hospital."
The physicians are very accommodating but their hands are tied by
availability of service.
Kaukab Usman had
a
heart attack after a gym workout in Windsor on Dec.
9. She was rushed to hospital and given clot-bursting drugs.
When
they failed, she was sent
to
Henry Ford Hospital
in Detroit, where
she had angioplasty on one clogged artery and two stents inserted.
It was a miracle for me to be alive," Ms. Usman said in a telephone
interview from Somerset, New Jersey, where she is recuperating.
Aaron Kugelmass, director of the cardiac catheterization laboratory a
Henry Ford Hospital, said
a
system is in
place
to
get these
patients
the
cale
they need expeditiously.
We try to make their length of stay in the US as short as possible,
Dr. Kugelmass, associate division chief of cardiology. "If they are stable
stabie
for
ans."
discharge, we discharge them to home in Windsor, with clear follow-up pla
wher
Cross-border mergency health care should become less
rida.
rida
Amr Mori, an interventional
cardiologist currently in Orlanu
comes to work at
Hótel-Dieu Grace Hospital in Windsor in April; a s
cquent
ond
interventional cardiologist is to come on board there by end or ye
year.
Reform
Health
207
Canada
is
the program fully
When
be able
ro
in
Care
to
do 500 angioplasties
the
The idea of starting
of the angioplasty
do more
them to
functional, Dr. Morsi
Detroit
is
program in Windsor
procedures
in
Windsor
of Toronto.
the University
decrease the numbers
take some time to
plan."
is the long-term
Bialkowski of Lakeshore,
Mr.
received four
stents.
The price
$40,826.21
bill
to a
to
of six,
a
document,
human
back
based in Windsor, is
did his cardiology
entirely, but that certainly
of Windsor, had
angioplasty and
was
a
copy of
resources
which
was sent
to
Mr. Bialkowski.
manufacturing company
manager for a
didn't m a t t e r where he
It
the gym and feels great.
it.
as he obtained
he said, just so long
me," he said.
took c a r e
at
lifesaving care,
Tguess the
send
hospital stay in March, 2007,
the
from Henry Ford Hospital,
35 per cent discount
$26,537.03 (US), according
Insurance Plan tallied
the Ontario Health
received the
town east
to
to
stents,
at
(US). With a
The father
without having
him, includinga two-day
health ministry
Source:
a
will be able
we
stainless
typically made of self-expanding,
blocked artery to keep it open.
the site of the fully
The
steel mesh, were placed
to treat
that
native who
London," said the Toronto
or
race
year.
a
training at
Tt will
expects Hôtel-Dicu
of
Canadian government
Priest, L. (2008, March 1).
Why
keeps sending patients
Ontario
and
south. 7he Globe
Mail, A1.
n
summary, the
key message
be financed less
of the
by gcneral
report
taxation
health
is that the
and
more
by
care
system
direct paynments
Mazankowski
this objective,
To further
such that
2001).
(Mazankowski,
Citizens
healthy,
to stay
O
emphasizes
encourage people
that such a shift would
ETTS
care
care system.
providing health
they would make less use of the health
c o s t of
awareof the
receive. In essenccs
to be m o r e
need
Consumers
that they
ould
Mazankowski
Out
M
Mazankowski
of
pocket for health
argues
that
care
services
schemes
user
c o m n m e r c i a l i z a t i o n
better-quality
Privateso
sector involvement will foster
Pvate
through
and
more
timeiy
fees and
Health Policy
in
Canada
208
CANADIANS: THE FEDERAL
THE HEALTH OF
ROLE (THE
KIRBY
KIRBY REPORT)
Senator
same
Kirby initiated a
time
as
Romanow
system at the
behalf of the federal
Senate study of the Canadian health
began his Royal
Commission
on
care
wrote a number of
Minister Jean Chrétien. Kirby
Liberal government of Prime
roles of the federal government in
he identifies the different
which
in
reports
and health care financing
the principles of medicare,
health and health care,
the final recommendations to
sixth report, which presents
the
is
here
focus
The
reform and
renew
medicare.
Independent Health Commission
Kirby
recommends
evaluation
the creation of an
of government
function independently
body or
to monitor
would be
to
the
council that
would
operation of the health
prepare an
annual report on
responsibilities
care system. Its primary
the health of the Canadian population.
care system and
health
the
the state of
important impetus to improve
2002). This body would
health
care
reporting would provide
consist of
o u t c o m e s (Kirby,
health
and
delivery
each of the five major regions
representative from
one provincial/territorial
an
Such
The federal
from the federal government.
five
representatives
and
Canada
in
As
million annually for council operations.
$10
would
provide
government
2012.
Health Council was abolished in
discussed in chapter 6, the
Public versus Private
Care Services
Kirby argues
that it is
not
Administration
and Delivery of Health
important who funds
or owns
health
care
services,
funder/
same: "The patient and the
he believes that the quality would be the
a
what the corporate ownership of
insurer will be served equally well no matter
the principle of
health care institution might be" (2002, p. 38). He asserts that
as
Act and other health
public administration articulated in the Canada Health
and physician services, but
care legislation refers only to the funding of hospital
asserts
"not to the delivery of those services" (2002, p. 7; italics in source). He
there has been widespread misunderstanding about the meaning of publid
funded and administered health insurance, and the delivery of health are
Reform
Health
services. Ho
have to
nothave
to
r
Cost
in Canada
209
Care
stresses that under the Canada Health Act, health care services do
be delivered
by public agencies" (2002, p. 8).
Efficiency and Medical
Savings Accounts
Kirby is convinced of the need to make the health care
effective and efficient (Kirby, 2002). Further, he ssees the system
system
levels. He argues for an infusion of
sustainable, given existing funding
as not
from the federal government, which he believes is required
s5 billion annually
unlike Mazankowski, Kirby
and renew the health care systenm. Thus,
to reform
as key to ensuring its long-term
calls for a strong federal role in health care
standards for medicare.
sustainability, and also to maintaining national
a
also recommends medical savings accounts as
Like Mazankowski, Kirby
overuse of the system (Kirby, 2002).
mechanism to prevent inappropriate use or
MSAs will help limit (if not eliminate) unnecessary
Kirby, too, believes that
health
on
Cimilar to Mazankowski,
more
use of health services, thereby reducing
care
funding.
Such
will also promote greater
accounts
public
financial pressures
efficiency in
health
care
operations (Kirby, 2002).
x Health Care Guarantee
of reliable data
acknowledges the lack
on
wait times for
Although Kirby
of a waiting list
perception
public
cites "strong"
Like Mazankowski,
particular procedures, Kirby
110).
p.
action
(2002,
for
problem as evidence oftheneed
to reduce
care guarantee
Nrby
recommends
establishing
a
national health
"such
a
guarantee
He argues that
and
for health services (Kirby, 2002).
standards, criteria
necessary
the
to the creation of
S e r v e as a spur
governments provide
it will e n s u r e
that
and
or
113)
in their o w n
1 a t i o n systems" (p.
health services
wait times
Ls
With reasonable
anadian
(3
access
province
or
(2)
to
needed
guaranteeis
territory. The
restore
public
considered
essential
the system;
confidence in
and
dollars
spend tax
government
of the capacity of
w
CIdence
implementing a guarantee
that
not
off
right
the
Turther, Kirby argues
will a p p r o v e
Courr
delhverea
mthe
system;
to
increasethe likelihood that the Supreme
individuals to pui
Prchase
n
care
private-issued
insurance
outside of the public medicare syste
privately delnvc
for privately
to pay for
Health Policy in
210
Canada
Primary Health Care Reform
with
continuing primary health_care rctorm,
creating multidisciplinary primary health care teams (Kirby,
reiterates the need tor
Kirby
emphasis
on
fee-for-service
2002). He calls for alternatives
capitation (health care providers being paid
to
arrangements,
for
set rate
a
such
as
serving a designated
approach. He also favours incorporating
into primary care. Kirby
healthpromotion and illness prevention strategies
$50 million annually to help
recommends that the federal government provide
population)
kind of blended
or some
the provinces establish
serving to
seen as
reduce
Devolution to
ot these arrangements
are
Health Authorities
Regional
health authorities (Kirby,
the role of regional
mechanisms into the
interest in introducing
Consistent with his
from
also favours
Kirby
primary-care groups. All
health care expenditures.
these
2002).
health
public
expanding
care
senior governments
services
argues for
devolving responsibility
of health
comprehensive range
on
finances and select providers
RHAs would control
to RHAs to
(Kirby, 2002).
the basis of quality and
Kirby
Kirby
system,
purchase
a
cost.
considers that devolution
eftective management
to
of health
these authorities would encourage
that
services. Further, he argues
care
(Kirby,
for finding timely
authorities would be responsible
because
regional
2002),
would either have
the
authority
not
was
possible,
individual. Ifthat
or
care for an
a
the local jurisdiction or to public
care provider in
health
to a private
to
more
regionalization will
ensure
the
go
private provider in
RHAs
Kirby
are
another
jurisdiction
also the mechanism
care
system
to
health
care
services
provide needed care.
by which internal
markets would be created.
mechanisms
"the introduction of market-like
internal market retorms
(Kirby, 2002, p. 70). He cites
defines internal markets
into the health
timely provision of
as
been
authorities as having
to regional health
responsibilities
that involve devolving
2002).
successfully in Sweden and the United Kingdom (Kirby,
implemented
Service-Based Funding
The current funding model for hospitals in Canada is elobal funding. In tn
model, health care service providers apply their funding to provide a ral
Health Care
Reform in Canada
211
ot
Kirby
se
ecific
with
shift to
service-based funding, in
activity, such as cardiac care or
hip replacements, are which
funding envelopes. Service-bas
provided
areas
set
recommends
a
af activ
of
Thospital
hdoeting and
funding
funding would replace
methods and include
what
population-based
funding.
are
This
all of the
called linc-by-line
means that
hospitals would
eive funding based on the type and volume of services
that they
cDanald, 2002-2003). To this end, Kirby
recommends that hospitals
Aevelop specializations, such as cardiologY care (Kirby,
rice-based funding would reduce costs and make 2002). He argues that
hospitals less
dependent
on government for financing.
Kirby's report reiterates many of the recommendations in
Mazankowski's health reform report. The key message ofboth
reports is to reduce the
nerceived dependency of the health care sector upon
government financing
of health care. Kirby recommends expanding the role of the
private
sector in health care and introducing a range of market mechanisms too
finance the system. However, he also recognizes the need for stable federal
financing of provincial and territorial health care programs.
BUILDING ON VALUES: THE FUTURE OF HEALTH CARE
IN CANADA (THE ROMANOW REPORT)
Prime Minister Jean Chrétien appointed Roy Romanow, former premier ot
Saskatchewan, to lead a Royal Commission on health care reform (Romanow,
with Canadians
2002). Romanow was to initiate what was called a dialogue
concern was
about the future of the public health care system. Of specihc
funded
the long-term sustainability of the universally accessible, publicly
medicare system.
Describing his
report
as
a roadmap for
their health
care
a
collective
journey by
system" (Romanow,
Canadians
2002, P.
Xxiu),
erorm and renew
is sustainable (Romanow,
care system
health
the
that
vision
1anoW presentsa
over a privarc,
a public
recommendations focus o n retaining
of medicarc
i i s key
as a principle
for-PrOIt service delivery and adding accountability
and Kirby reports,
n
a n a d a Health Act. In
committed
to
the Mazankowski
In
system.
the existing public
contrast
strengthening
Sustainability of the public health
to
terms
considers
of the
the tocus
Romanow
care system,
"inadequate."
He
argues
that
the
be "narrow and
2002, p.
1)
dLainability "means ensuring that sufficientservices" (Romanow,
nnancing and
long term to pro
over
available
money to
Oprovide
are
s o u r c e s
timely access to
quality
212
Health
Policy
in
Canada
Public versus Private Care
Romanow notes that a key element of his commission's mandate was to make
recommendations
t o ensure
the
long-term sustainability of a
universally
accessible, publicly funded health care system" (Romanow, 2002, P. 1). He
considers the role that MSAs, various user fees, public-private partnerships,
and other market-related mechanisms could play in a reformed health care
number of
system. On the basis of the available evidence, including a very large
commissioned reports, Romanow concludes that all of these have shortcomings,
with serious implications for the accessibility and quality of health care services.
the title of his report-Building on ValuesNot
surprisingly, considering
he calls for a recommitment to the principles of need over income as a guiding
evidence that health
principle of medicare. Romanow provides
financed and managed.
m o r e effective when publicly
should
be
not
With
spending
are
entitled.
to
financial
regard
on
commodities, he argues, but rather
seen as
which all citizens
health
care
sustainability,
compares
with
countries in the OECD
Romanow
favourably with
public
health
care
imbalance that has
recognizes the funding
territorial
and the provincial and
He
in federal
been
to dedicate
as
essential
notes
goods to
that Canada's
that of other
developed
2002).
systems (Romanow,
between the federal
appeared
governments as a
result of steady declines
have
result, the provinces
health
of their budgets to
proportions
increasing
and requires
is under-resourced
contributions since
required
systems are
Health and health care
care
the 1980s. As
a
health c a r e system
He argues that the
"stable and
He recommends
maintain
sustainability.
dollars to
Health
m o r e federal
form of a "cash-only" Canada
the
in
federal funding"
care.
predictable
Transfer (Romanow, 2002).
Health Care Guarantee
caution
recommends
the m a t t e r of wait times for care and
Romanow considers
care
(Komanow, 2002). He acknowledges that
care guarantees
and
in
approaching
guarantees
can
reassure
patients,
initiate steps to
hospitals to
limits established
an
objective
service
or
in
a
treatment
cuee
ensure
guarantee.
assessment
and require health authorities, providers,
can meet time
that the health c a r e
Yet,
he adds
of
ot the capacity
within
a
the
specific period
nauiring treatment.
that guarantees
system
of time
must
be
based on
r
e
q
u
i
r
e
d
to
and
on
the urgency
of the
213
Health Care Reform in Canada
Overall,
that
Romanow is concerned
provided with the Hexibility
2002).
surgical procedures (Romanow,
systems be
to meet care
Direct and
manage emergency and elective
Care guarantees might introduce
resources
Ancillary
care
to
away from lite-saving surgery
other health care services.
guarantees for
and could direct
rigidity
provincial and territorial health
or treatment
Health Services
and ancillary health services (Romanow,
Romanow differentiates between direct
health services are cleaning and food services within hospitals.
2002). Ancillary
He recommends
public funding
of
diagnostic
and
treatment
services, but
make more
out ancillary services to reduce costs and
supports contracting
services.
resources available for medically necessary
that most Canadians
Romanow advocates this distinction on the basis
of ancillary services by for-profit agencies
accept the provision
currently contract
(Romanow, 2002). He adds that many non-profit hospitals
He argues that, based on the
out these services to for-profit corporations.
services should be provided in public and
available evidence, direct health care
the consequences of private delivery
not-for-profit health care facilities, since
seem
to
can be life-threatening.
Box 7.2: What Is
Commission's Final
Missing in the Royal
Report?
The
care.
Report quite clearly fails
Plans that fail
to
take
to
women
health
gendered analysis of
into account [are] not only inadequate
provide
a
but also inequitable.
even
of for-profit delivery,
prohibition
The Report fails to
the problems with such delivery.
though it presents evidence demonstrating
for
recommend the
Ihe
Report fails
entirely
to
consider long-term
care, chronic
people with disabilities.
he
ne
Report fails
Report does
to
discuss reproductive
not
apply the lessons
issues
on
and
access to
these
services
international agreements
in the
the other recommendations
chapter
al
they could have a profound impact on them.
to
care or care
Report, even
set out
thougn
214
Hcalth
Policy in
anada
What Does the Report Mean for Women?
We
applaud the Romanow
medicare. A
publicly
the sustaining
Commission for demonstrating
funded
system
through non-proit
in Canada. But like other reports
crucial for
all
in the last
decade, this Report fails
women
delivercd
to
recognize the
on
health
of
services is
care
significant ways
reform
in which
health care is an issue for women. Women are 80% of paid health care providers,
a similar proportion of those providing unpaid personal care and a majority
of those receiving care, especially among the elderly. The sustainability of the
it is about women's work and women's care.
system is not just about hnances,
health as a human right, it should
Just as Canada should be a leader in seeing
also be a leader in promoting gender equality in Canada and globally.
Investing in health care means investing in
planning for care is
bound
to
fail in its
women.
Unless this is understood,
objectives.
Health Care Reform and Women.
Adapted from The National Coordinating Group
Future of
the
report ofthe Commission on the
(2003). Reading Romanow: The implications of final
Centres of Excellence for Women's Health.
Health Care in Canada for women (p. 53). Winnipeg:
on
Source:
Expand Medicare
include home care
expanding the scope of medicare
in the
care services to support people
to
Romanow recommends
final six months
and palliative home
Romanow also recommends developing a
of their lives (Romanow, 2002).
to informal
by making them
program
to
provide ongoing support
eligible for special benefits
under Canadas
caregivers
Employment Insurance program.
Romanow recommends developing a national formulary of prescription
medications to ensure consistent medication coverage in all provinces
and territories.
work with the provinces and territories to ensure
The National Drug Agency would
consistent coverage, objective assessments, and cost effectiveness.
Relationship to National Forum on Health Findings
Of all the health reform reports, KomanowS report is most consistent with
recommendations made by the National Forum on Health. The National Forum
lauunched by then Prime Minister Jean Chrétien in 1994 to engage Canadians
Health
Carc
Reform
in Canada
215
liscussion about health
th carc and to
recommend innovative ways that the federal
government could improve the health care system and the health ofthe population
Eorum on Health, 1998). The National Forum was set up as an advisory
minister and the federal minister
of health. Thisbody saw its role
body to theprime
considering the long-term and systemic issues associated with health and health
T h e National Forum commissioned several papcrs on systernic issues and
volumes on key health issues. It provided several recommendations
roduced five
the health care system and the health of the population.
to improve
on how
Recommendations
Box 7.3:
Among the
recommendations
of the National Forum on Health
of the National Forum
sustainable
system is already
public is preferred over private
add
accountability
public
the
to
Canada
were:
Health
principles of
Act
and
portability,
universality, accessibility,
administration,
comprehensiveness
include home
care
improve timely
services
access
approach health
care
to services
guarantee
based
with caution,
on
principles of
fairness, appropriateness, certainty
investigate pros and
cons
of private diagnostic
services
workers' compensation
ANALYSIS OF
REFORM
THE HEALTH
reflect
t00
a
diverse perspectivesbecome
Romanow reports
has
system
Kirby, and
medicare. The
reform
to manage
lack C o n s e n s u s - o n how to
professions
The Mazanowski,
and
REPORTS
large
Incrcasing
ut
amounts
of moncy
with little commitment
strcngthen
to
responsibility
Mrcngthen. the
public health
significantly reform
the health
being
are
available to
system,
reform the
to
and
the part of
on
government
politicians
They
unwilling
system.
nner
in which
and health
care
services
activities
health
health
are provided,
m o n i t o r e d
are
to
seem
provided,
urance
care
manner
providers are paid,
2005; Walkom, 2011).
made
care
it.
(Rachlis,
ca
care
2004,
lcalth Policy
in
Reform
Canada
Health
in Canada
Care
216
217
nrofit
of the Romanow Report from the
Preliminary Analysis
and the Canadian Labour Congress
Canadian Health Coalition
Box 7.4:
does
does n o t
care, there
not happen.
clarified
looked
Overview and Broad Principles
to
at
It does
aPpear
to
be
a
mechanism
the Canada
include these services under the act. The
more
rhe
uring that this
recommend that
closely.
Romanow Report
alth Act must be
Report
needs
to
be
offers some
important steps forward to
preserving and expandingmedicare for today and for future generatione
h
it is just a starting pOint. It has established some fundamental principles thar
The Romanow Report on the Future of Health Care concluded that thera
is a consensus among Canadians that medicare is a moral enterprise, no
need to be built and expanded upon.
a commercial venture. Canadians believe that equal and timely access to
medically necessary health services on the basis of need alone is a right of
Public-Private Partnerships
citizenship. The core values that underpin medicare remain the same: equity
fairness, and solidarity. As a result, Canadians reject diluting the principles of
The Report rejects the argument that [for] Public-Private
Partnerships to
design, build and operate health facilities, such as hospitals, will save the
medicare, scrapping national standards, paying privately to get faster care, and
treating health care as a business
public money. Romanow notes that these agreements have been shown to cost
In his message to Canadians, Commissioner Romanow said, "1 believe
more over the longer term, and can have the effect of
hospital bed closures
and a reduction in nurses and other health staff. Romanow
stops short of
recommending no Public-Ptivate Partnerships.
it is a far greater perversion of Canadian values to accept a system where
money, rather than need, determines who gets access to care." The Report
clearly states that Romanow challenged those advocating user fees, medical
savings accounts, de-listing public services, greater privatization, and a
system to provide him with evidence that these choices
would improve or strengthen the health care system. He clearly said that
"The evidence has not been forthcoming." There is no evidence that these
solutions will deliver cheaper care or improve access to care. Further, the
parallel private
principles underlying
these solutions
are
directly contradictory to the values
of Canadians and the values of medicare.
For those reasons, the Romanow Report rejects a parallel tier of private,
for-profit
care
for the
delivery of what he calls direct health care
services such
surgical care. This conclusion is to be applauded.
Medicare.
for-profit care will harm, not improve,
be drawn berween
a line
that
However, the Report mistakenly says
such as laundry, food preparation,
health services and ancillary services
as
medical, diagnostic, and
on evidence that
It is based
can
cleaning, and
for
delivery
maintenance
in the private
services
approach. These
are
health
care
Services a r e
people who
staft, and
services.
sector.
are
workers, and
are
the public.
While
movement
and those
health services
see
themselves
health
pertinent to the
sick, and the
These services are said
The labour
workers. These
Good nutrition
is critical
Is essential to
cleanliness
has rejected
a
Romanow
rejects
these alternative
medicare. In the end, all of these
Co-payments, Tax
measures
measures
to
raise
violate the
core
and
more
fundingg
for
principle of equiry
equal access to care based on need for care. These measures promote access
based on ability to pay.
MRIs and CT Scans
ne
Keport
calls all
diagnostic
services
required
to assess a
patients
neea
Or nealth services to come under the conditions of the Canada Health Act,
ding
the prohibitions of
CHA should be
amended to
user
fees, facility fees, and extra-billing. The
clarify this.
be appropriate
disagrees with this
who provide them
care
as health
of patients.
of hospitals
the Report
to
Medical Savings Accounts, User Fees and
Credits, and Deductibles
to
CHST
he
Report calls for federal health funding to be taken out of the CHST and
This transfer would be
nto a new transfer-The Canada Health Transfer. federal
that
funding would
an escalator clause
and
have
transfer
s-only
1he CLC has called
so
patients,
parallel tier of for-
keeppace with economic growth and
O
this since
the CHST
was
our
put in place
ability
in 1995.
to
pay.
Health Care Retorm in Canada
Hcalth Policy in Canada
218
219
Primary Care Reform
of the Public System
Expansion
The
Act
that the Canada Health
recommends
Report
include home
care
services in
priority
should
be
This would include
areas.
We
post-acute
a
coverage of palliative
home care, including drugs
months of life. Also, it would inchud
six
last
home during the
care in the
Home mental health services
of support for informal caregivers.
a program
It calls for a Catastrophic
and rehab services,
should immediately
come
as
well as
in
drug plans. Eventually,
the CHA would
Transfer to help provinces
It calls for a creation of a National Dmn
of prescription drugs.
cover the cost
the
insure
safety of drugs and it also calls for the
and
Agency to
control
establishment of a
control
Drug Formulary to help
costs.
training
The
to
gain
Report states
access to care
that the
violates the
current status
of
health
to
accessing
care
should be
a
care.
Funding: Making Medicare Sustainable
Finally, it
must be an effective dispute
of the Patent Act. There
calls for a review of aspects
dedicated Health Transfer would he
The
CHA.
in the
mechanism maintained
and conditions in the Act. The Report
connected to the principle
direcly
Access Fund to attract and
of a Rural and Remote
calls for the development
for health professionals
including opportunities
retain health care providers,
health providets
n u r s e s and other
doctors,
experience for
in
a
barriers
costs
National
multi-disciplinary teams in community-based setting. All funding sources
Aboriginal
pooled into new Aboriginal Health
Dartnerships Fund. The goal is to improve access to care and provide adequate,
erable funding. The system needs to reftect cultural diversity and
language
for
D
under the CHA.
with their
Care Iransfer
Primary
should drive changes to the
primary care system.
needa common national platform for health care reform. Prevention
and
romotion initiatives would be part of this. Primary care needs to be delivered
The
revised to
Civil Society organizations have called for the federal government to increase
its share of health funding to 25% of publicly insured health services. The
Romanow Report recommends that the federal government move to this
standard by 2005-06 with increased funding in each of the next three years.
The Report calls for new federal funds to bring the federal share up to 25%
of insured health spending provided under current provincial plans. This will
require additional investments to be added to the current level of funding.
injured workers getting preferred
access to care for all Canadians,
This would mean a new investment of $3.5 billion next year, 2003-04,
be
followed by an additional $5 billion the next year, 2004-05, and a $6.5
principle of equal
This exception needs
to take place.
Act allows this
The Canada Health
to
billion increase in 2005-06. By 2005-06, these increases will bring the federal
cash transfer to $15.3 billion per year. Romanow assumes that this will equal
reconsidered.
25% of the public health services insured under provincial health plans. An
Accountability
calls for the
establishment
of a
new
Canadian Health Covenant
Report
force for Medicare.
values and would be a guiding
which would state Canadian
and assess the
would be established to analyze
A Health Council of Canada
include
would
in the Council
national health system as a whole. Membership
be
should
Health Act
the
providers, and governments. The Canada
The
escalator clause will increase this cash floor according to economic growth.
These funding arrangements need to be stable and predictable. These funds
would be targeted to specific spending areas over the next rwo years.
Table 7.1
public,
2003/04 (S billion)
revised to include a Sixth Principle of Accountability.
billion)
Trade and Health Care
Diagnostic services fund
In recognition of the threat to health care from globalization, Roman
sends a clear message to the federal
health
care
in trade
agreements
must
government that current
protections for
not be weakened. Future expansiol
and
actions must be protected in all future agreements. The rightto regulate heale
Care
policy should
not be
subyect
to
claims from
2004/05 (S
foreign companies.
75
/
Rural and remote access
Primary health care
1.0
1.0
Home care
Drugs
TOTAL
1.5
1.0
1.0
3.5
5.0
221
220
Healh Policy in
Canad,
Health
Care
Retorm
in Canada
if the required
2005-06, the federal transfer for that year would rise from
$5 bill
$6.5 billion, bringing the total federal cash transfer to $15.3
billion th0
In
that y
rhat
analysis
Council
of the Romanow Report from the Camadian Health Coalirion and the Canadian Laba
u
Otawa: Canadian Health Coalition and Canadian Labour Council.
reducing r e s o u r c e s
the role of
result in reducing
ad
row
Soure: Canadian Health Coalition and Canadian Labour Council. (2002), pelmt..
co-
wonder, however,
2003). Observers
is feasible, given their tendency
levels of government
between the t w o
eration
and opting tor privatization schemes
to the system
tainability (Maioni,
New
Box 7.5:
government
Institutionalism
in health
care.
Concepts and the Prospects for
Health Care Reform
As
a
result, the federal and
provincial and territorial governments tinker
at the edges of the system by delisting services and privatizing increasine
elements of the system. All of this further reduces the role of govetnment in
institutionalist perspective, institutions structure political debate
that will be considered to address public problems (Hall,
solutions
and the
1996). In health care, federal and provincial institutions
1993; Hall & Taylor,
Erom a new
providing publicly organized and managed health care. Already, the Canadian
tend
health care system provides significantly less public coverage of health servi
in
than do most developed nations (OECD, 2015). Thus, central to health care
reform is the debate between public versus private financing and delivery of
health care services.
to
impede meaningful
relation
to
the
provision
retorms
the health
of
funding
of sufficient
care
system, particularly
its sustainability.
to ensure
The ongoing wrangling between the federal and the provincial and territorial
gOvernments over the financing of health care has led to litle productive
debate on how to change the system with the goal of improving it. The rwo
levels of government can be seen as structuring the health care debate, often
by limiting the range of solutions that can be considered to reform the system
Values, Principles, and World Views
resistance
consistent with the market
Mazankowski's and Kirby's visions of health
Stone explains how the market treaus
approach defined by Stone (1988, 2012).
health care become
care are
individuals
as consumers
and how
public goods
commodities. The market is characterized
works to
acquire goods and
however, does
not ensure
services at
such
as
by competition, as each
the lowest possible
quality ofthe goods and services
cost.
individual
Competition.
traded and sold ina
market when applied to health care.
Market
apPproaches
create
inequities in
access
for vulnerable poplanou
who lack the income to move up in line to receive the health care servi
they require. If faced with paying health care
costs
such
as user
fees,
expresss
only
Romanow
recognizes these
issues an
pharmacare,
t h cane
confidence in the overall purpose, function, and form ofthe pubi
hi
couches
Romanow
system, yet he also identifies areas for improveme
the system.
is an
continue
support.
ealth
Opting
for
private
expanded role for the private
2000, 2001; Langille, 2004, 2009;
Savas, 2005). It
prescribes roles and relationships for private institutions and
government within a
sociery. The private institutions identified to improve
sector
measures
or an
ideological position (Coburn,
ces, medical savings accounts, and public-private partnerships (Stone, 1988,
014). What happens in these arrangements is that the service good charged
e
or
private entity in the end
belongs
bace
back gements
into the
care and
Romanow confirms public confidence in
hea
public
Ystem to ensure
recommends major new federal
investments in the systc
are
in
place,
to
that entity. Critics argue
it is dificult
public sector.
express
report in the notion of values and reinforces the notion that medicar
a value of
equality that Canadians
to
early
1964 by Emmett Hall's report to the federal
government.
In contrast to Romanow, Mazankowski and
Kirby recommend introducing
some
privatization measures, such as user fees for services, in order to sustain
ealth care represent the market and market-oriented strategies such as user
peop
with low income will simply do without.
Of these reports,
and improve service delivery and health ourcomes. There is also institutional
to expanding the system not
only to provide suficient resources
to core funccions of medicare, but also to
expand the scope of the system to
include dental care, home care, and
as recommended as
as
Presen
esent
to
bring
these goods
that once
or
services
but
ports are concerned about the sustainability of medicare,
r y different solutions to ensure it. Mazankowski recommends user
feesand medical
savings
accounts
(MSAs)
to
reduce
inappropriate use. Kirby
222
R e t o r m
Health Policy in Canada
recommends public
over
private funding
but also
recommends MSAs f
or
reasons similar to Mazankowski. Komanow
unequivocally states that publi
funding makes the most sense and notes the lack of evidence that
privatizatinn
will improve the qualiry of care. These and other aspects of the
reports
those
Jim
Stones distinction between the polis and the market
Stone,
1988: Romanow, 2002), it is clear that the market underlies Mazankowskit
approach to health care reform. He implies that making the health are
ro
by
undo
key
strong federal role in health care. Neither considers health care a commodiry
co be bought and sold in the market. but rather a public good. Romanow cites
medicare
understand
gains that
those gains,
standards
only
set out
precisely at
furious when federal Finance
Minister
non-negotiable scheme Monday. Justhy so.
were
Stephen Harper's Conservatives threatens
nada has made in the past
we nave to
understand
eight years.
what medicare is. Ir
ie
incentive for
to
has
no
individual provinces to adher
Act is that doing so allows
in the Canada Health
from Ottawa. But
get cash
1968, medicare has
chem
in
The
the provinces.
government
In contrast. Romanow and Kirby reftect the polis in their emphasis on a
governments
from health care
most,
Minister
from Prime
new plan
national
solutions, such
overuse ot health care services.
money and jobs
needed
his
u
formally unveiled
Flaherty
To
as MSAs, to
also recommends
privare
ensure the
sustainability of the health services system. His aim is to make consumers
more aware of the cost of health care and to discourage inappropriate use or
provincial
are
arional public health insurance scheme administered and partly funded
system run more like a private business will ensure its sustainabiliry, H
or
they
when
times
Most
Drawing on
market
223
emove
slumpperiods, i t
refer
different conceptions of sociery and how to deliver health care.
Canada
in
Care
Health
since
its
been under attack from
business in hcalth
inauguration by the Liberals
those who think the federal
care.
Indeed, it was a Liberal government that, in 1977, first devised a way
to gradually extricate Ottawa from what had been a 50-50 cost sharing
arangement with the provinces. The Liberals did so by first tying annual federal
evidence that shows that public health tacilities provide better-quality care
health transfers to the ups and downs of the economy. Like Flaherty, they
than private health facilities. He also cites the evidence showing that private
explained this as a cost-saving measure. More important, they began to count
any tax room ceded to the provinces as part of their health contribution. The
use of these so-called tax points allowed successive Liberal and Conservative
health
health care systems. Romanow's
systens are more costly than public
views of the Canadian public.
the
with
consistent
are
and perspective
care
hndings
Bovernments to gradually reduce the actual cash they transferred to provinces
By 2002, Ortawa was contributing only 18 per cent of the public cash going
to medicare. An
increasingly unenforceable Canada Health Act was on its
way
to
Box 76: Walkom: Why the Harper Funding Diktat
Endangers Medicare
Ottzwas
into
health
rules
care
recommended
boost in federal cash contributions.
federal-provincial health accord wo years later was so
mportant. That accord eliminated
any linkage between federal health transters
and
economic growth. More
important, it committed Ottawa to put morc
And it is
plan to cut back health funding threatens to make medicare
why
a
the
al cash into medicare. Thanks to that accord, the federal governments cash
unenforceable. And this is only stage one.
By Thomas Walkum. National Affairs
share of
health-care funding has gone back to about 25
up
per cent.
new
plan very carefully doesn't mention the accounting nctio
anerty's
Ioonto Star
Cing
ultimatum b
neditare, the federal
tieat and
becominga dead letter. This is why Roy Romanow's 2002 Royal Commision
del1terate
governmcnts new health fin.ancing u
step batkward. By scaling back cash contributt
tions
prvinial medicare plans, ir will graduaily and inevitably destroy
ability to enforce the (Canada Health Act. By
tying these contribu
vagaties of the overall economy, it will make it harder for
long-term health-care surategies. And by
cutting back
to
Ortawas
to the
provin
spending during
health spe
t a x points. But even so, the Conservative arrangement wouid
return the country to where it was in 2002-with Ottawa puttng
t o medicare and the federal government losing all ability to
orce
Standards
age
two
that Canadians accept as
given. Think ot tnis as
has not
yet been announced. But ic is intriguing to
Ottawa still wants
see that
n t s to continue talking to the provinces about health, even as it
imsists that the
nain
main topic
top of contention-money-is non-negotiabic.
Reform
224
Health Policy in
talk about?
My
Canada
they
Canada
225
Heath
guess is "lexibility"
the
provinces that he plans to eventually starve them of cash, Ptime Mini.
What will
in
Care
Having warned
nister
Stephen Harper can now tell the premiers that hell turn a blind eye iftheustry
ROx
etter
Innovation or Federal
Leadership?
cnilled in describing and explainingg the
development of
lthcarepolicy across Canada (see, inter alia, Taylor, 1987; Short, 1981; Maioni,
These studies have pointed to a number
1999; Boychuck, 2009).
itions
and spirit of medicare.
Provincial
Much ink has
to make up this shortfall through creative solutions-even if such solutio
(delisting of all but core services? user fee?) run direccly counter to the lee
7.7:
1998; Tuohy,
disinctively Canadian experience: some scholars
al-democratic government in Saskatchewan
theinnovation edge of a
point
onstration effect of provincial experiments; some indicate the
the demons
of factors
that
ount
account
for
for
the
to
December 20).
Source: Walkom, T. (2011,
from
Toronto Star. Retrieved
Why the Harper funding diktat endangers
endangers medicarc.
www.thestar.com.
and
federal-provincial dynamic that allowed for the creation of a "collaborative" fiscal
and somelook to the elusive notion of
framewo
"nation-building
federalism
rhat is sometimes
reflect two competing world views (Maynard, 2007)
In short, the reports
the libertarian ideologies. The collectivist appros
and
collectivist
These are the
behaviour of social institutions. Roman ws
as the goal of the
promotes equality
orientation. Kirby, however, favous
collectivist
avours
the
and Kirby's reports represent
while also supporting a Strong
mechanisms,
other
privatization
and
user fees
Mazankowski reflects a libertarian world view with his
federal role. In contrast,
and a smaller state role.
more out-ot-pocket payments
emphasis on incurring
recommendation to shift to service-based
Of particular interest is Kirby's
role for regional health authorities
an
expanded
and
funding for hospitals
It
seems
to
contradict
his overall support for
fortified
by federal funding.
the
in health
state
a
and Sinclair
fundamental
Kirby's analysis fails
to
shift in
national health
highlights his
care.
Grieshaber-Otto
represents
It also
a
(2004)
hospital
desire
to
care
system
reduce the role of
service-based funding
argue that
that
Moreover, they add
funding.
authoriis
local health
and
recognize that hospitais
accountable to
the
public as
become more
these institutions
that
may become less
Sena0
elected governments. They suggest
independent of democratically
would improe
developments
these
that
and his Senate colleagues believe
Kirby
the policy changes that
the functioning of the system, thereby validating
& Sinclair, 200
and his committee think
are necessary
(Grieshaber-Otto
receive
for peopie
Kirby's recommendation that governments payfundamental roblemof
P 2004)
address the
treatment in other jurisdictions may not
& Sinclais
the federal government's underfunding (Grieshaber-Otto
authe
situation by
Thus
In essence, the proposed remedy could exacerbate the
additional spending outside the local setting
at
private
market
ratesa t such
p r o f i thealthcntitis
Grieshaber-Otto and Sinclair and other policy analysts
arg
may result in increasing reliance on private, for-pro
provide health care services (Grieshaber-Otto & Sinclair,
measures
to
20U
.
enduring legacies
Two
The first is
wav
attached
for
that
policy.
to
the historical
stand out,
experience.
however, in the historical
institutions matter; the second is that
The absence of federal
policy leadership,
social-democratic government, led
narratives
politics paved
the
combined with
an
provincial innovation
interventionist
lhe stability dittusion, and expansion of
experience).
Saskatchewan
(the
Saskatchewan and across the other provinces, however,
this experiment in
involvement of the federal government, which
fiscal
the
depended on
to use fiscal levers in the absence of policy-making capaciry
attempted
But the history of these fiscal levers has shown that, while effective in deterrence
to
they less useful in trying to deploy or encourage policy reform
of the ebb and flow of fiscal
system change. Instead, they have become part
offederal
fcderalism in Canada--an instrument
budgetary exigencies, rather than
The
for
health
instrument
pendulum" efect applies to
policy-making.
specific
and compliance,
are
or
a
a range of policy areas (see Simeon & Robinson, 1990), but the case of healthcare
ilustrates it best. In the earliest years ofcost-sharing programs, through the Hospital
Insurance and Diagnostic Services Act of 1957 and the Medical Care Act of 1966,
there
was a
hefty financial
commitment-an investment, in many ways-on the
part of the federal government to pay specific amounts engendered by provincial
spending, But berween 1977 and 2003, block transfers became the financa
of choice,
from provincial healthcare policy
federal
nstrument
severing
financing
and the Ten-Year Plan,
With the introduction of the Canada Health Transfer
as of 2004, federal fiscal involvement has amounted to the equivalent of a serieso
Dlank
cheques rather than a
xcerpt from Maioni,
Dia
T.lowarde a
commitment
to
policy leadersnp
A. (2015). Politics and the healthcare
policy
arena in
Canada
Nossal (Eáis,
Dixon, and K. R.
situation, evaluating solutions. In A. S. Carson, J.
Studies.
School of Policy
226). Kingston: Queen's
Healshcare
Strategy
Canadians, (p.
227
Canada
226
in
K e t o r m
Health Policy in
Canada
Care
Health
eriences in the public systems of Singapore and
experiences
on
rch literature h
have
been implemer
implemented,
a v e been
Deregulation and Accountability
where
Kirby and Mazankowski believe greater competition will lead to
more
innovation and better quality of care, but cite little evidence to
support
claims. They seem unconcerned about the lack of accountability tha these
result from an expanded private sector role and further deregulation of may
care. Mazankowski criticizes medicare as an unregulated monopoly, yet fa
is unclear
deregulation will
quality of services, or how it can maintain public accountability.
further
deregulation.
It
how fhurther
"The
constant
theme
current structure
throughout
our
of the industry is
work was the
tragmented
too
gdom
lway:
satistactory
responsibility and leadership
Commons lransport
of
House
(UK
performance"
and
of
5-6). Such fragmentation
the Canadian health
further
and
care
commercialization
a
complaint that th
to
provide clear
basis for
improved
rail
p.
blurring of lines of accountability may afe
system,
in health
allow
care.
consideration of public solutions to remedy the
There is need for more
Foremost is a need to renew the state's role
problems of the health care system.
benefits of the single-payer system.
the
health care and recognize
in
Medical
Savings Accounts: Path
to Prudent Consumer Use
of Health Care Services?
The Fraser
favours
an
BC,
Vancouver,
think tank based in
of user
introduction
and the
expanded role for the private sector,
other userlets
and
MSAs
that
is
Their
Institute,
fees and MSAs
will reduce the
a
public policy
(Ramsay, 1998).
cost
American evidence
premise
of care, and, in particular, reduce
shows that "MSAs
are
conducive
taxes.
They argue nt
prudent ncuu
to more
individuals' health...
pending without compromising
costs" (Ramsay, 1998).
n lower employer and employee
They
have
Further,
resulted
the
r0.20
Institute suggests that MSAs could lower health expenditures D up
percent (Ramsay, 1998). The rationale for such measures is to make coe
n s u m e s
services.
more aware of the cost of health care to reduce their use of health cale
exacerbate
MSAs may
Moreov
are
individuals
ervices
i n c o m e
In
(Shortt, 2002).
costs
costs
suggests that the approach
fact, MSAs mav
inequalities in publicly funded systems. Low
becaus
ause they will choose to do without
disadvantaged
if they
use
consequences for
fatal
up the
some.
funds in their
Ihey may not
MSAs.
have the
Such actions may
hnancial resources
con:
o
in
purchase
health care
private
care
anadians
raises
in the
remain
concerns
Canada Health
committed
(Romanow,
care
o n a n expanded
private sector role
about meeting the five principles of medicare
and Kirbys emphasis
Mazankowski's
Inred
services.
to a
argues in his report,
ublicly funded and administered health
pub.
Act. As Romanow
2002).
system
Regionalization of Health
lines
Committee, 2004,
should Canadian governments
rol
c o n t r o l
ealth
Moreover, experiences with deregulation in other jurisdictions Suo
che need for caution (Grieshaber-Otto & Sinclair, 2004). Deregulatio
icopardizes accountability and obscures lines of authority. For exam
ample,
the House of Commons Transport Committee in the United Kinedo
plans
such
not
does
result
improvei he
identified serious faws in the organization of the privatized
China,
trend in health care retorm has been the
growing interest
of health-that is, the devolution of decision making in
local authorities. Regionalization means that responsibiliry for
Another important
he regionalization
health care to
services is referred to municipal or regional governments.
the delivery of health
is that local o r municipal governments are
for
rationale
regionalization
The
perceived as best positioned to identity, and are most responsive to, local needs.
it is seen as compatible with their mandated responsibility for public health,
such as sanitation, support for new mothers and families, and maintaining and
improving the health of the population. Several provincial governments have
opted for regionalization based not only on this rationale oflocal responsiveness,
but also to reduce provincial health expenditures.
By the late 1990s, nine of 10 Canadian provinces had devolved health
care decision making to local authorities (Lomas, Woods, & Veenstra, 1997).
Regionalization meant the vertical inregration of health care services. The
VErtical integration of health care refers to the entire range of health care
viCes, from
out-patient to hospital and long-term care services. By the late
0s, Ontario had
regionalized its health care system, bur health care
were organized locally. In 2004, Ontario announced
Ad
that public health
health
services by creating Local Health Integration
t would regionalize
not
services
OTksLHINS). The Ontario government created LHINs in 2006 through
e Local Health System Integration Act, 2006. The legislation invested
gnincant
decision-making power
at
the
community level.
229
Canada
225
Health Policy in
Problems with regional1zation
en
identificd.
The
related to its
population
health
design
and
discourse has
in
Reform
Care
(anada
implementation
translated
not
mandated programming. P'opulation health and hcalthy
been key features of some local public healthcomm
programs had long
n
i
ograms,
Such as those in the City of Toronto, Peterborough, and other
cross
on the potential effect of vertical in
Canada. Concern centred
ublic health identiry and funding. and the idea that regionalsar on
Healeh
and
o w n ,
build.
domain.
publice
tional
-are
To
infrastructure
and services that were
previously in
the
Union
FPublic
Public
of
and General Employees. 2006. p. 1). The National
a
D.hlic and General Employees argues that P3s are privatization in
Union of Pui
for the public to challenge these
litle opportunicy
arrangements
There is
what are public
vices.
t o provide
s
e
as
c
r
e
t
.
the best
way
as
that to consider privatiz
merely a call to reduce
SDending is a "serious misunderstanding ot the concepr" (p. 2). in
argues
Savas (2005)
th
af public health could result in units that are to0 small to support
op
T m
many
health coalitions, P5s signity "privatization by stealth"
health
any
r
local
cxpertise and could impede the development and enforcement of prouie
bvince.
che authors of Bad Medicine, Langille, and others, he argues that
contrast
wide programs. There was also concern that citizen involvement in
ealth
merely political rhetoric. In addition critics
care decision making
that regionalization would increase rather than reduce
concern
expressed
was
"privatization
implemented,
can
be at least as compassionate as the weltare state: properly
it offers
even
moree
for the less fortunate among us" (Savas.
2005. p. 2).
cOsts (Sutclife, Deber, & Pasut, 1997). Regionalization in the 1990s was
three methods of privatization:
Savas considers
care, since th
clearly diferent from previous plans
was
no consensus on whether devolution was good for Canadian health care.
1.
to
regionalize health
Much of the interest in regionalization
concern
provincial and territorial governments
the efficiency of service delivery,
the federal and the
with reducing health spending
improving
improving equity
in service
participation and more accountabilicy of
provision,
In some provinces, regionalization
1998).
&
Barker,
decision makers (Church
the scope of public health when it should have
into
and
ensuring
citizen
2.
reducing
had translated
been amenable
more
to
expansion (Sutcliffe
et
Delegation: The government
maintains overall
responsibility,
but
uses
the private sector for service delivery, such as contracting for services,
or outsourcing. Savas says that this can be understood as "partial
privatization" because it still requires an active state role while the
stemmed from
al., 1997).
production or service activity is carried out by the private sector.
Divestment: The government withdraws its responsibility and
presumably transfers it to the private sector. This is "competitive
sourcing. Savas notes that this is the dominant form of privatization
in the US and is used by federal, state, and local governments. He
describes it as "the most direct form of delegation."
3.
Public-Private Partnerships
Displacement: The privare sector expands and "displaces" (usurps)
a government activity. Savas considers this development to be a
Another reform adopted by provincial and territorial governments is public
powerful incentive for public agencies" (2005. p. 5).
in health
attributable to changes
private partnerships (P3s). The adoption of P3s is
territonil
care
Provincial and
hnancing, particularly by the federal government.
involvement in healtn
increasingly consider expanding private sector
governments
care delivery to reduce their health budgets. Health care costs increase annualy. In
n contrast to critics of P3s and privatization of health and social services
avas
hoW
suggests that P3s
are
innocuous. Savas fails
low-income and other vulnerable
populations
demonstrate, however,
would benchit trom such
to
addition, reduced federal transfers for health care result in provincial andtc
arrangements.
governments paying more for health care.
A P3 is an arrangement in which a
government and
ersargue that Canada must approach public-private partnerships and
he Council of Canadians, the Canadian Centre for Policy Alternatives,
a
tity-
private enu
t aprivate corporation, individual, or agency-jointly provide a puble
orgood (Savas, 2005).
e
unit
It refers
relationship
between one gov
and a consortium
of private firms to build, for example, a highwy
the 407 in Ontario, a
hospital, or a school. In other words, a B
may contract with a
private entity to enable that entity to
to a
nance,
h
desi,
commercialization warily and with tremendous caution (Barlow, 200/
to
&
haber-Otto
the
Sinclair, 2004). Turning over any public good or service
private sector to deliver for profht violates the principles of medicare as
outli
n t h e Canada Health Act. A preferable form of private involvement
in
a
public health care system is
one
in which the
private provider is non-proht
and
Reform
Hcalth Policy in Canada
230
regulated by government statute.
accountability.
For
example, hospitals
This
are
how they spend public
to
deliver
public health
care
health
undermines the foundation
of claims for
principles
is open
es,
of
to
on
It may also shift
14). Starr
policy" (Savas, 2005, P.
welfare state programs as a function of structures and
of
erests.
privatization
P3s is provided by Janusz Lewandawdl:
An alternative definition
first minister of privatization, otherwise known a
post-Communist Poland's
Transtormation." He defined it thus: "the sale of
of
Ownership
"the Minister
and whose value no one knows, to people who
one
owns,
enterprises that no
He might have added, "And who will make
2).
2005,
p.
(Savas,
have money"
delivery.
renewing government
of
and
medicare around the
While
delivery of health care services.
lelivery of what he terms "ancillary services," such
and other
evidence
His m a i n
the provinces
c o m m i t m e n r to
versality and non-profit
private
no
rt
cost
osten
echoing the sentiments of the National Forum on Health,
cleaning,
Lhas found
the specific form
depending
f that
clearly identifies the movemenr ward th
to
-medical
Romanow
care,
suPPOrt a larger private
sector
as
food
acknowledges
that
role in health
care
oint is the need for stable and secure federal
to
territories in order to provide universal and comprehensive
funding
(Maioni, 2003).
health
retorm reports vary in their commitment to allowing
main
three
The
The
care,
lecting in part the conflict berween the polis versus the market
care
of
result of the
and
Romanow urges
It shifts power to those who can more readily exercise power in the market.
more as a
care,
as
public purpose and public servic
income and wealth,
a s m e a n s to make Canadians
aware of the
nd ostensibly to reduce utilization of health care services.
savings
n
Interestingly, Savas cites Starr's (1989) opposition to privatizatio
an example of ideological and political opposition to P3s: "Privatizai
231
accounts
medical
for
services.
Canada
owide heau
health care servICes. Both Mazankowski and Kirby support
entities provide
relationship helps to cnsure
private but not-for-profit. Th publ
cy ate
governed by their own board of directors, but are accountable to governme
dollars
in
Care
Health
programs
private
as devised by Stone (1988, 2012). The polis signifies a focus
the public interest and the collective in identifying and realizing goals. In
concepts ofsociety
on
contrast, the market society consists of individuals who, by competing with
transaction."
cach other to promote self-interest, bencfit the whole. In health care, as in
many other areas, emphasis on the market may distort the operation of public
policy and lead to ineffective and inequitable outcomes.
ISSUES
CURRENT HEALTH CARE
issues they
little has changed. Many of the
Since these reports were released,
care seem
and
emergency
times for specialists
identified remain issues today. Wait
increase in
as a result of the
in
intensified
has
part
to have increased. This issue
those with higher incomes.
health clinics that meet the needs of
private
This examination of recent reform proposals in Canada demonstrates this
between the polis and the market. In health care, the polis reflects
tension
the collective desire to provide access to health care to all members of
society
the basis of need, and the market
represents increasing privatization of
health care and the commodification of care.
on
commodification
and health
care
is
associated with growing
outcomes.
Evidence suggests that such
in access to health care
inequities
CONCLUSIONS
sustainability ot tne
reform in Canada has focused o n the financial
to
on whether
centred
has
public health care system. Much of the debate
Primary
private involvement to ease some of the p r e s s u r e o n the public system.
Health
care
aio
health
CRITICAL THINKING QUESTIONNS
What do you think
care
issues
(Dixon, 2013).
public
iealthcarereform represents alocus site for governments to and
health care spending. The health reform
Mazankowski
reports of
innovation
.
n
welcome increased
health care. Kirby,
considers that
private sector involvement as
however, supports the
aciple
there
a
is little
difference
in
whether
vehicle for
of public financin
in
l
forpro
non-pron
are
the main
drivers of the call for health care retorm
Canada? How should
medicare be reformed?
W Can various
health care reform?sectors in Canadian society have their voices heard in
in
care is seen as the logical area to reform to address a number of onc
What extent
4.
do
you think Canadians
driving the health care
reform debate?
What are
personal views cerning
health care your
system?
are
aware
of the various
forces
the future of the Canadian
Chapter 8
AND
MARKETS
HEALTH POLICY
INTRODUCTION
Since
the 1970s, social
and economic
changes have dramatically restructured
he olobal economy, specihcally the processes of production and investment
ISchrecker & Bambra, 2015; Teeple, 2000; Grieshaber-Otto & Sinclair,
2004).
In addition, concerns about rising deficits that
began in the early
1980s drove both federal and provincial and territorial
governments to reduce
sOcial and health spending (Scarth, 2004). Developed economies
such as
Canada, the United Kingdom, and the US responded to these
changes by
adapting their economies and deregulating business activities in a number of
public policy arcas.
One aspect of this
increasing emphasis on economic
been nations with
public health care
such
systems
functioning
has
Canada and the United
and market mechanisms t
as
Kingdom increasingly looking to the private sector
deliver health and social services.
National governments
justify these changes as
essential to enhance their
in the new
competitiveness
(Banting,
Hoberg, & Simeon, 1997; Bakker, 1996). From the global economy
perspective of the private
Sector, health care in
particular represents an attractive investment opportunity
(Grieshaber-Otto & Sinclair, 2004).
nis chapter considers these increasingly important health care markets in
analyzes the situation in the United
where market
Lanada. It also
proaches
to
health
in chapter 7,
care
delivery have become
Kingdom,
increasingly
common.
As
central and recurring theme in the debate over health
in Canada
orm
and in the United
of th
is a call to expand the role
private sector-or the marker-in Kingdom
health care provision. This chapter
considers the impli
both the
a
mplications of an increasing emphasis on health care markets tor
health
care
system:and population health.
237
Health Policy
238
Health
in
239
Policy
and
anada
Markets
associations, informal agreements, and market power, such as price
MARKET?
WHAT IS A
t
r
Regulations govern what can be traded, as well as
occur.
Regulations also infuence costs, profit
e r e trading
orher aspects of the trading process. Leys suggests that it is at this
aintenance (Leys, 2001).
a
d
e
can
market is a complex set of social institutions that enables the exchangc of
commodity such as a good (housing) or service (health care) between a
when
seller
ofshaping
mode of exchan
the processes of buying and selling good
or commodities. These goods and servicescan be
2000).
and buyer (Leys, 2001; Teeple,
of
through
needs
society
that meets the
The market is
thus
a
juncture
that
and services as private property
also include what are usually termed basic needs, surh
health care services, but
and recreation, among others.
education,
housing, food, income,
of distribution is based on competitive supplr
the
market,
process
In the
The market also comes to represent a
and demand in the exchange process.
income, and wealth are distributed
and
capital,
which labour power
means
by
and consumption. Inequalities in suh
processes of production
in political power and influence
differences
to
distributions may also give way
the effects of the market
innovation,
of
source
a
Although often presented as
even
or
beneficial
benign. The market
not always be
on societal processes may
economic forces that influence
and powerful
to represent significant
since
may come
a r e n a s . This is especially important
health policy and other public policy
Markets
2001).
and power (Leys,
interwoven with markets are politics, ideology,
economic
through
influence beyond their purely
have considerable capacity to carry
the public policy arena.
realm into the broader society and
81) because politics
Markets
are
"highly political" (Leys,
market activities as
much
as
do the
2001, p.
processes
shape
the politics
margins (Leys, 2001). Understanding
health
pouy
functioning, including
societal
to infiuence many aspects of
on a society. Mas
to understanding their impacts
is
development,
integral
and imp
forces influence
driven policies emerge when global economic
financing
domestic
policymaking. These issues are
and management
of health
care
services
ecially
in the
(Leys, 2001; Whiteside, 200)
how
Leys (2001) identifies the characteristics of markets that help explair
they function and influence health care policy. This is particule
particularly
helpful
and others towa
understanding the current orientation of governments a
8Overnments
market mechanisms to control health care
costs.
First, markets are systems
of rules
consisting
enforced by both state and non-state
and
and
regulations
a c t o r s throu
agencies, including market a
their
own
resources
market politics come into play. Despite the
to
how
create
regulations, increasing attention
companies and corporations can adjust the rules to
advantage. These companies
to accomplish
and
corporations possess considerable
this.
complex. This is the case since any one market
complex of marke that involve transportation, raw and
c o n s i s t s of
actually
and
materials required for product development, insurance,
manufactured
is
one
market
embedded
That
is,
2001).
any
others (Leys,
advertising, among
in a broad series of other social relations.
directly or indirectly
markets also participare in other social relations,
Those who work in
relations refers to the pattern of relationships
Social
them.
and are shaped by
the group or organization in which they function (Hale,
in
berween people
relations such that they come to accentuate other
1990). Markets shape social
that the more important these social relations
political issues. Leys suggests
tend to lead to and accentuate other larger
market
a
in
are, the more changes
Second,
markets
are
a
health care
For example, changes in the rules and regulations by which
services are organized and delivered may infuence the ability of certain groups
to access
and influence health
care
services. If there is increased
delivering health care services, and these services are turned
emphasis
over to
on
the marke,
then physicians and other allied health care professionals, such as nurses, may
AVe less ability to influence the course of health policy. And if these newly
Cnpowered,
privately organized
providing access to marginalized
service
providers
are
less concerned
groups, then health consequences
witn
for these
marginalized groups may emerge
also affect the
creasing market mechanisms for health care delivery may introduction
the
CHARACTERISTICS OF MARKETS
for
is
ption
being paid
regulations that
states or governmen
political issues.
and pront
of cost, revenue,
their
power
and
of markets
nportant
and
margins, and
i o n of income and other economic resources. To make
PProaches more attractive to citizens, governments may oner tax
s.
thar benefit primarily well-off, higher-income individuals and households
ince public health care systems tend to ahave distributional effects-the well
off pay
creation
them less-the
O
r health services in taxes., but tend to use
of health
service
from lower-income
income
of
transfer
vice markets will lead to a
be
gFoups to higher-income
inanced less out of
Or
then
comes
care system
groups. The health
sources, such
m o r e by private
and
revenues
general
_
to
as user
240
Health Policy in
Canada
Markets
and
Health
Policy
241
fees. As discussed elsewhere in this volume, those least able
also the most likely to require health
shifts to market approaches.
Third, markets
are
inherently
able
to
pay-wwho are
services-are especially affected
by
unstable
(Leys, 2001). Their
policy
eflects the nature of competition. nstability is a function of
other market sectors always trying to increase their market industry
share, which
the proportion of industry sales of a good or service that is controlled
firm.
Ihese
or
processes may be seen as beneficial to
individual company
market
competition, but it may be problematic when they include the
provisic n
of
basic needs, such as health care services.
In addition, Leys (2001) argues that market success endows
eater
pOwer in the market itselt, possibly at the expense of society as a whole. As an
example, Leys suggests that global fhirms can come to take over and control
national market, potentially curtailing or discarding certain services. Leys cites
the example of Rupert Murdoch's News Corporation dominating the national
8.1: Privatizing Health Care is Risky for All of Us
Martin
Danielle
andMail
The Globe
and Irfan Dhalla
By
In poll after poll, Canadians reaffirm their commitment to a health-care systemn
in which access is based on need rather than wealth. So it stands to reason thar
opening up medicare to a private second tier would be bad for people who
have no choice but to rely on the public system. With a relatively fixed number
of health-care providers, wait times in the public system would increase as staff
were recruited to the private sector. From Australia to Zimbabwe, this scenario
has
unfolded repeatedly around the world.
But, deep down, some of us wonder: It T had the money to buy my way to
the front of the line, wouldn't I be better off in a two-tier system?
The answer, perhaps surprisingly, is probably not. Private health care
as bad for the
as the
wealthy as for the poor, as
newspaper market in the United Kingdom, but one can imagine health services
would be almost
coming to be dominated by exceptionally powerful private sector health
corporations. Competition and its resultant side effects are central to how
system provides high-quality care (and most Canadians who use the system
rate it highly).
The reason is, there's such a thing as too much health care-too
many tests,
too many interventions and too
many pills. The emergence of for-profit health
care in Canada would
produce just this situation-not enough health care for
some, and too much health care for others.
markets work.
THE RATIONALE FOR MARKET COMPETITION
This is
on
competitive market (or health care markets) is based
economic theory, which claims the superiority of markets over
control and regulation of health care (Rice, 1997; Leys, 2001). Some polig
The belief in the
government
analysts and national and provincial/territorial policy-makers have com
to
Delleve that such markets are key to reducing health care costs and inp oving
the quality of care.
The assumptions from economic theory include the following: (1) marke
are
the
source
of innovation;
(2)
and
deregulating and privatizing health s
Services will facilitate such innovation; (3) these activities will allow redu
state role in
these
and operat
ciencies in
result (Coburn, policy areas; and (4)
& Bambra
2001;
Schrecker
2000;
Teeple,
2001;
And it is clear that such beliefs are Leys,
increasingly being put ro
policy debate in Canada (see
Box
The
emphasis on the market 8.1).
is
consistent with the
supported
ported by political
politica ideologies
central
a
cost
2015
c h ehealth
ta
traditional econome
tenets of
theory. These ideologies provide the neoliberalism and
rationale for
ud
emphasizing
m a r k e tp r o c e s s e s
long
exactly what happens
in the United
States, where
public
people
with
private health insurance find themselves subjected to the risks of unwarranted
procedures. The U.S., for example, has the highest rate of invasive cardiac
procedures in the world45 per cent more than the next
highest country. Yet,
all these
additional procedures have not bought Americans better heart health.
wOrse
still, each invasive cardiac
EOus
complication--stroke,
procedure
a torn
carries
a
coronary artery
small but real risk of a
or even
death.
mlarly, in a two-tier system, the wealthy would be bombarded with
I C e to
ger
"checked out," and
many
would end up receiving
unwarrantca
reening tests such as CT scans, hich produce enough radiation to increase
the risk of
cancer.
e
there were a well-devcloped private health-care system in Canada,
Wealthy would still need to use the public system for many rori
care, for example-because the private system would tocus O
lcesuma
elective
and outpa
for
The erosion of political support
patient
probably would result in
for everyone
public
care
medicare
care.
worse
care
ealeh Pollu y n
Aulketn
anul
Fleal1h
Pli
Jiberal aryuichts
Neolil
A
y
wo
tet 8ytCm
In
an would be bad for bunlnens,
laster accem to n o r e
health
rare,
copoatonn
a
worlel
WOjld
wlher
wal
De cxected lo ay
for thelr employees 1o Jump to the ronm of the lIne, Sone Cahidan bunine
do this already,
punchaslnp
too
mumeh healh
physiealh,f
care-executlve
provieling l00 mu
examplefor thelr most-favoured employeen. "The cont o
CEO
understand thin
alrendy.
Charlen Baillie, the
former
eone trAive
aeryices as pootental
ilk of funding, and
and
hanker-as a corporate leader -becaune I believe it'h high time that we i
the private nector went on record to make the cane that Canacda's bealth-(ae
other
private
becau poilicy-1akers can vicw
inestne, which will aholve
interational
markets. ealthh
a cAnnocdity and nota
ain health carc ervices. In
incomes to olbtaini
(u
ofTD Bank, said a few years ago: "| choone to talk aboun health care
ite or
y turning, donestic
at ional private healtih care resyponeibilities.
ayenies t finance and
provide health
ec,
Cnts and respnibilities Can be
Care mer
private sector
leadlead, to the crcation of health carereduced, yet turníny, the
gove
public service, People
becon
health care for a larpe proporton of the work force wold be enormo
Bank
health
ir
for health
respons
euivers,
mot
care
then
become reliant
o
additicn, privatization increaes the
individual households and
primary family
wonen
(Armtrong, Arstrong, 2010). Front
care on
of whom are
lnehealth care workers, cspecialy nurses, are alo advcrely affected by reduced
xystem is an cconomic annct, not a burden, 0ne that today, more ihan ever, ou
overnment uransfers and increasing, privatization. Armarong and Armstrong
counmry dare not lose."
(2010) document the fragnentation of urning work, which is refected in the
growing number of categorics of workers providing care-egjstered nurses,
Sourer: Martin, D.,
he Gitobe
.
Dhalla, I. (2010, Novenber 11), Privating, healh
Reitheved from
and Mal.
cave
bn
sbky for alo
www.sheglobeandmall.com
in several public policy areas, but their effccts are cspecially important wlhen
One of the central Ienets of ncoliberalism is that a market cconony
bet allocates resources, inchuding income and wealth, in a society (Coburn,
2001; Schrecker & Bambra, 2015). iovernment policy-makers and electcd
representatives concerned with health care are Cspecialy sunceptible to
neoliberal arguments for several reasons. Health care services providedby the
do not generalc
rcvenues
and
coOnsume
among thc
carc, Armstrong and
the qualicy of
Armstrong (2010) atribute
fragmentationn not only to medical developinents, but also to presures "from
governments and hospital administrators concerncd about finances" (p. 102; ec
Armstrong & Armstrong, 2010, for a full discussion). We are back to the reason
the
patient
considering health care policy.
ate
nurses-in-training, nursing assistants, nursing aides and orderlies, and therapists,
among others. The increasing division of nursing work has implication or
health care was made into a public affair: to have health services
provided
basis of neced, not income! When the state
provicdes health carc, health
decommodified; in other words, it is not a market
for which
must
pay
out-of-pocket
for the
commodity
carc
they
receive.
on
the
care
people
most resources of all
HEALTH CARE MARKETS
public olicy arcas.
Private
financing comes in different
forms, but what they all share in common
markets. In addition to medical savings accounts,
Box 8.2: The Cost of Medicare
IS
In a recent report on mnedicare, the Fraser Institute argues that Canada spenab
ovCrhment can transfer the financing and delivery of a health carc service to
the
creation of health
care
CCS,nd contracting out scrvices, among others identified in chapter /, a
more on heal1h care than other industrialined countries in the
for Fcononic Co-operation and
Development, and provides "interior
carc comparcd to thosc countries without a public health care system
Organisatlon
&Walker, 2005). Purther, the institute argues that all of the countrics
calth
have fewer years of lifc lost to disease and lower
mortality have private
Care systcms and user lees at
point of access to health care services.
Cprivate
sector as
represcnted by public-private partnerships
(P55).
discusscd in chapter 7, a P3 is an arrangement between the public
public scctor
dclivered (Grieshaber-Orto & Sinelair, 2004; Savas, 2005). There
h
of P3 modes, with considerable variation in the degreeto
has
N private sector
or
s.
CCtors to
provide
a
project
or
service that the
be privatizcd
end, public asscts might
Other P3 arrangemens
sector
to
operate and managc.
Cprivate
Iranslerrecd to the
is involved. At
one
is
Health Policy
in
by public
s
Canad
Markets and Health Policy
244
245
may
to
involve
contracting
out
proviaca
the
may have
private
sector
operating
these arrangements
servantu
2004). sStill
Sinclair,
(Grieshaber-Otto
firms
private for-profit
arrangements
scrvices normally
&
(Arms
donc under.
be
particular
doctor
tors, and other health
strong & Armstrong, 2003,
managing public
may
a
hospitals,
and i
short.
of
privately owned
arrangemments may also varv in
indefinite periods. P3
their
or
term, long-term,
control, anc private risk involved
government
degree of accountability,
facilities. All
markets represent
These
markets includ
lude
ambulatory
carc,
the
provision
among othcrs.
set
of social relations that
professionals provide
shapes how
patients
potential new
care to
2010; Leys, 2001). These
of laboratory tests,
pharmaceuticals,
and
Box 8.4: Public-Private Partnerships (P3s)
the Market
Box 8.3: Policies for
Tim Rice (1997), a professor in the School of lPublic Health at the
of California
at
Los
Angeles, identifies the different types
mechanisms in health
by advocates of market
providing
"new
pas oenerate
moncy only to the extent that they can
generate a revenue
stream from a source other than the government that would not otherwise be
versity
of policies
espoused
awailable
carc:
in order
to
receive
requiring people
to
pay
more
in
premiums
to
obtain
more
Provincial
governments
determining how much
a
used
British
in Ontario, Alberta, and
Columba
build schools, highways, anu
in intrastructure to be conducted via public-private partnership5
concerns
about the
which
extent to
risk
financial
orohis
remains situated within the public sector in P3 arrangements, yc
accrue to the private sector (Rachlis, 2004).
of P3s is
a
to
allow
governments
way
to
employ public
assets for
to remove
Some argue the
xpenses
from
prina
accoun
public
P3s may not only lead to the creation of health markets,
web of other markets and commodities such as those i1n t
a l s o
c r e a t e
purposes that the
public
Source: Mackenzic, H. (2004).
Financing Canadas hospitals: Public alternatives
Ottawa: Canadian Health Coalition. Retrieved
from
would
not
In
to
P3
(p. 5).
www.healthcoalition.ca/wp-content/
uploads/FULL-REPORT-October-2004.pdf.
numerous
8.4). Critics have expressed
as a
hardly a justification for the concept.
country
such arrangements to
ese
that
u
has publicly stated
hospitals. In addition, the federal government
a significant investn
Box
approaches are underutilized in Canada and provide
have initiated
example, a private hospital operator might
support or to generate revenue at levels that the public would not support is
their distribution among specialties
diffusion of medical technologies
deregulating the development and
eschewing government
spends on health care services
For
of "new money, however, these examples highlight the broader public
policy
accountability issues raised by P3s. The fact that P3s can, in principle, be
extensive
health insurance coverage
number and distribution ofhospitals
allowing the market to determine the
the total number of physicians and
and
and what services they provide,
involvement in
government.
charge higher tolls to highway users than the government would be able to get
away with politically. Far from supPporting the argument for P3s as a source
health
care
money out-ofpocket
having people pay
whose demand is most responsive to price
services
for
services, especially
more
the
covered by medicare. Similarly, it may be that Highway 407 was worth more
to the successful bidder, 407 International, because it expected to be able to
people with subsidies to allow them to purchase
rather than paying directly for the services they use
low-income
hcalth insurance,
to
be able to generate revenue by oftering medical services for sale that are not
Canada, hospitals are private,
not-for-profit facilities governed by their
the provincial
territorial government
provide health care services.
all hospitals remain
Although
in the
non-profit in Canada
United Kingdom, some
in both countries contract out for
hospitals
erVICes such food provision and cleaning
cOt, 2001). This practice has increased (Armstrong&& Armstrong, 2003, 2010;
have limited transters
pltals,
forcing hospital CEOs to make up governments
to
gaps by contracting out some services
them from the
private sector. In the UK, hospital CEOs have reduced
Der of registered nursing positions in order
ne number of nurses available care for to save money. This change
Ihas
patients
implications for the quality
hospital ward and
ality of patient care in
hospitals.
boards of
o
directors, but receive funds from
own
or
nd
as
as
to
to
on a
246
Health Policy in
United Kingdom,
In the
monopoly
on
health
the National
care, similar to the
Hcalth Service had
a
single-payer
public hospitals, car parking charges, and renting space
farkets
virtua
system of medic
Canada (Leys, 2001). In the late 19805, however, initiatives such as pav.
in
in
to shops and bus beds in
a
charge
budget
ere
an
important area
for investment.
in
Box 8.5: Public Private Partnerships in the United Kingdom
By Dr. Allyson
on
to
accounting systems
capital and
pay
for
this
new
as
for the
debt...
first time the UK NHS had t
pay
in the revenue or
creating
operating
The repayment ot these very expensive PFIs
a stream
meant
A number
ofsubsidies had to be
NHS under enormous pressure.
was merging hospitals to release
was
land
sales.
The
second
found. The first
for sale. You might say it was sensible rationalization
land and buildings
more
resulted in major service closure and the diversion of incom.
inevitably
hitt it
caniral ernr
ants
smaller facility. The third was a diversion of
for the new
to pay
into
facilities
off
the
debts of the new
paying
intended for public
increased market-sector involvement, such activities can only increase. H
will become
our
the
introduced to bring in revenues to hospitals (Scot, 2001). Some Carn
hospitals have implemented similar mcasures to generate more revenues,V
care
247
Polic
cy
Health
and
Canad
budgets
PFI hospitals.
Pollock
Sounce
Excerpt from
presentation
a
made
The policy of public private partnerships [PPPs] or private finance initiatives
(PFIs) as they are called in the UK was a policy dreamed up by the then
of the
Conservative government in 1992 to bail out the failing construction
College London.
I don't know exactly what models are being proposed for the P3s
in Canada, but given that the same management consultants are advising
Romanow
CUPE. (2002). Experts tell
industry..
designing, evaluating, implementing and promoting the policies Canada as
in the UK, it
likely there will be a remarkable overlap. The decision to
first
rewrite the federal government's capital investment manual is a significant
PPPs.
of
lines
UK
step to reforming Canada along the
a source
PPPs are not a neutral financing mechanism. Neither are they
in
for the
on
Commission
Health Policy and
(pp. 1-4). Ottawa:
by
Pollack
Allyson
Dr.
at a
technicaì
brieñng
the Furure of Health Care in Canada. At the time. D. Pollack
Health Services Research Unit
commISSO7
Canadian Union of Public
at
the School ot Pubic
on
was
P3s
bead
Policy, Universiry
ha: Public-privae parmersiips are not
zhe a s u e r
Employees.
seems
.
debt financing. In other words
new
money or investment. Private finance is
it is a source of borrowing which has to be repaid-either out of the public
of
purse
or
roads. It
by giving the private sector a
is
not a
neutral
financing
concession
mechanism
of the National Health Services (NHS).
.USing PFI is more expensive for
to
raise
as we
user
charges as in toll
show in detailed studies
the rolled up interest that
accrues
two
higher cost or
by virtue oflong repayment perio
to
Detter-quality
is cost-efficient
care or
the
Teeple,
support
privatized health care provides
Doctors tor
(Evans, 1997; Canadian
to support
evidence
much
is
there
2000). In fact,
gnincant government intervention in
order
to ensure
equal
access to health
care and lower health care costs.
AUS
study found
that
user
fees
at
for-profit hospitals
contributed
blood pressure,
to a
because
20
they
high
nE higher risk of death for people blood
under control (Brook
pressure
EC less likely to see a doctor to get their
to
were as likely
deter the
1983). The same study showed that user fees
nly
rate
schemes. In addition PFI results in enormous cost escalation.
coming
public health concerns. The government ca ney
Justity the higher cost of the PFI and PPPs through the value for m
debts
analysis. But the real issue for public authorities is how private hnan
are to be
repaid. In the UK, National Health Service (NHS) private
1S
repaid from the revenue budgets of hospitals. This necessitated a
to
the view that
Ihere is little evidence
FI
s and
borrowing money in advance. That adds a huge burden to the cost o
Now
ON HEALTH CARE
Medicare, 2015;
reasons-the
borrowing (government borrowing is always cheaper) and the financing cos
which can add up to 40% of the total costs of schemes. The financing c
are
DEREGULATION
THE IMPACT OF MARKET FORCES AND
anc
n a n c e
7 A s s i v e
with
use
of health
care
services
as
they were
to
deter the
inapproprate
fees
shown that user
other studies have
Calth care services. Similarly,
services that they may
care
from using health
may
Health Care
p0or and elderly
Foundation for
Canadian
1995;
achlis & Kushner.
D
Improvement, 2012)
Health Policy in
Canad,
248
Another study involving
a
review and meta-analysis of studies com
ompared
mortality rates at private, for-proht hospitals and those at private, not-for.
Drofit
hospitals
studics,
(Devereaux
including
more
Findings based on 15 observatin
and 38 million adult nae:
hospitals
26,000
et
than
al., 2002).
and
Health
U.S.
Costs: How the
8.6: Health
o
u
n
t
r
i
e
s
B yJason
)
Kane
private, not-for-profit hospitals. (Findines were
risk of death comparcd
confounders, such as severity of illness
of
etc.)
adjusted for a number possible
available study
the
that
single
of infant mortality showed.
The authors report
risk at for-profit hospitals. These higher mortality rates m
may
10 percent greater
and less well-trained staff at private, for-profr
to having fewer
PBS Neus
to
be attributable
The authors concluded that:
hospitals (Rachlis, 2004).
is
at a
The Canadian health care system
would be better
suggesting that we
A
recent
account.
(Devereaux
Health
have
care
example,
of privatized health
compared the
administration
costs
costs.
many
For
health
systems. Consistently, private
care
not as
much
tn0
which
cOst-etfhcient because there is one place to send all the invoices and from
201)
(Yalnizyan, 2006; Canadian
octors
for Medicare,.
With a central location for paying and receiving paymer
system reduces
administrative
costs
by
not
the single-
duplicating administr
largest
diferent methods of payment. Moreover, as the
single suppler aes for
buyer of health care services, the government can negotiate better pric
products and drugs than may be the case for
multiple purchasers.
as
many Americans expect.
other OECD
people in
79.8 years.
IS more
receive payment
developed
between 1960
Lite expectancy at birth increased by almost nine years
and
and 2010, but that's less than the increase of over 15 years in Japan
American
over 11 years on average in OECD countries. The average
than one year below the average of
now lives 78.7
years in 2010, more
with
to
most
The number of hospital beds in the U.S. was 2.6 per 1,000
2009, lower than the OECD average of 3.4 beds.
is associatcu
Indeed, considerable evidence shows that the single-payer syste
than
people-well
per
public health care
& Himmelsteul
higher administration costs (Woolhandler, Campbell, 2014).
Geissler,
Low
&
2003; Himmelstein, Miraya, Busse, Chevreul,
are.
health
financed
with
administration costs are associated
publicly
of
more
upP
There
studes
care to
times
than in most
are fewer physicians per person
countries. n 2010, for instance, the U.S. had 2.4 practicing physicians
below below the OECD average of 3.1.
1,000
and
the impact of organizational
health care (Bambra, Garthwaite,
on
markets may also increase
is
Worth it?
two-and-a-half
rich European countries like France,
the world, including relatively
ons in
nation.
a more global scale, it means U.S. health
On
United Kingdom.
Sweden and the
Americans
17.6 percent of GDP A sizable slice of
of
financial health system reforms o n equity
that private insurance and out-of-pocket
found
authors
The
&Hunter, 2014).
either
of health services, have
marketization and privatization
expenses, and the
inconclusive or negative equity impacts.
figure
care worth to you? $8,233 per year? That's how
person.
more than
34 member nations-its
In the United States:
al., 2002, p. 1405)
evidence
review examined the
That
health
spends per
of
their decisions
et
is good
the U.S.
world."
"the best health care in the
the U.S. has
cents
17
what
every U.S. dollar is purchasing. According
But let's consider
for Economic Co-operation
the
from
Organisation
recent
report
to the most
international economic group comprised of
(OECD)-an
and Development
served
outcomes
evidence into
much
much
now eat
concerns
by
How
Care costs
but
politicians-say the cost may be unfortunate
including some top-ranking
individuals
by private for-profit health care
about the potential negative
review raises
delivery. Our systematic
care. Canadian
associated with private for-profit hospital
health
them and the public
influence
to
seek
stakeholders who
policy-makers, the
should take this research
whose health will be affected
Compares with Other
Box 8.6:
C
found that private, for-profit hospitals had a small but reliable 2 percent igher
crucial juncture with many
49
Policy
Marke
here's
a
bright
side,
to
be
sure.
health
The U.S. leads the world in
care
rate ror
a n d cancer treatment, for instance. The five-year survival
OECD countries and survival
Cancer is higher in the U.S. than in other
m
colorectal cancer is also among the best, according to the groupP
Th
rooted out of the "assembly line
ncept is pretty simple: If waste is
and
outcomes, in this case)
proce
result will be better cars (or health
the
officials
Medical Center in Seattle, top
4Osts. At Virginia Mason
tests
from
unnecessary
t h a t hospital "waste" can look like anything
Health Policy in
250
to
elaborate waiting
rOoms to
full report.
fora
In the meantime,
from its
global peers,
we
poorly designed floor
plans. Tune
and
anada
to
the
they monitor how many generic drugs a physician is prescribing and
update on where the U.S. stande
Mark Pearson, head of Division on L
Gan send someone from the insurance fund to visit physicians' offices
lealth
to encourage them to use cheaper generic drugs where appropriate. In
comparison, U.S. payment rates are much less flexible. They are often
the
NeusHour: Where does
U.S. health
care
spending stand relative
statutory and Medicare cannot change the rates without approval
a
by
osother
to
Congress. This makes the system very infexible for cost containment.
OECD countries?
There are few methods for controlling rising costs in private insurance
o r its econommeasured relative to its population
Pearson: Whether
far the most in the world on health care.
spending
in the U.S. In running their business, privare health insurers continually
face a choice berween asking health care providers to contain their costs
the
spends by
or passing on higher costs to patients in higher premiums. Many of
in 2010. Norway, the
on health per person
The U.S. spent $8,233
are the next highest spenders, but in the
Switzerland
Netherlands and
less per person. The average
all spent at least $3,000
same year, they
on
251
countries also supplement lowering fees with other tools. For example,
Policy at OECD.
United States
Policy
hev can intervene by lowering the price for that service. These
in
more detailed
spoke
Health
Markers
health
care
other 33
among the
developed OECD
countries
them find it hard
to
do the former.
from Kane, J. (2012, October 22). Healch
Source: Adapted
Neus. Retrieved from www.pbs.org.
PBS
other countries.
costs:
How he U.S. compares with
was $3,268 per person.
but even so, it devotes tar more of its
very rich country,
in 20010-to health than any other
GDP
of
economy-17.6 percent
of GDP and
next highest, at 12 percent
the
is
Netherlands
country. The
the
of
U.S., at 9.5
half
that
almost
was
the average among OECD countries
percent of GDP...
cost-containment
is possible to have
France and Japan demonstrate that it
to those used in
tools
using similar
The U.S. is
at the same
a
time
the U.S. There
as
are
paying physicians
three
key things
that stand
out
when you compare these
countries to the U.S.
They
use a common
fee schedule so that hospitals,
U.S., how much a health care service gets
paid depends on tne i
ind of
insurance a patient has. This means that health care services can cho
tnan
other
nsurance
patients who have
enerously
policy that pays them more
lower-paying
insurers, such
as
edicaid.
Similarly, in France an organization called
dissatistaction" (p. 438). He cites the United States as a key example ofallowing
aket forces
to
Dergence of
ECT
how
prevail
provision. Elsewhere, he has criticized
"zombies," bad ideas that keep coming back no
in health
user fees
as
many times they
are
care
buried
(Evans, Barer,
& Stoddart, 199).
ceeding
seems
what
they budgeted for. In Japan, if spending in a specinc
be
growing faster than projected, they lower fees to
with interior system performance-inequiry, inefficiency, high cost, and public
icu
Ihey are Hexible in responding if they think certain costs are exe
to
system, spends more on health care than nations with public systems. Table
8.1 shows health spending for OECD member countries. These reports show
that in 2012, the US spent almost 16.4 percent of its gross domestic product
(GDP) on health compared to, for example, Canada at less than 10 percent.
Evans (1997) argues that that international experience over the last
Ccentury has shown that increased reliance on the market tends to be "associated
doctors and health
SerVices are paid similar rates for most of the patients they see. In ne
patients who have an
In support of this argument, the Organisation for Economic Co-operation
and Development consistently shows that the US, with its market-driven
that area
CNMATS closely
nitos
area is
spending across all kinds of services and if
see a
they
pa
reres
growingfaster than they expected (or deem it in the
puI
i n t e r e s
INGUISHING BETWEEN ALLOCATION AND
DISTRIBUTION IN HEALTH CARE
As stated earlier, the
for marketiz
crier, economic theory
on
which neoliberalism is based calls
t i O n in health care. Anyone who advocates market mechanisms
252
Health Policy in
Table 8.1: Total Health
Expenditure
as a
Share of GDP.
201
012
1eh care
Public
Australia
5.9
Austria
7.7
8.7
Belgium
7.9
7.2
3.4
10.1
Canada
Chile
Czech Republic
Denmark
5.9
8.8
4.6
6.4
Estonia
Finland
France
8.5
Germany
8.2
2.8
.3
3.0
5./
1.5
1.2
2.1
2.3
2.6
Greece
6.2
2.9
Hungary
Iceland
4.7
2.8
7.0
1.7
Ireland
5.5
n
10.2
5.5
1.2
5.7
3.1
3.0
6.1
6.1
5.5
3.2
6.3
6.4
Spain
Sweden
Switzerland
Turkey
United Kingdom
United States
Source: Organisation for Economic
Rice, 2011).
sociery must make allocation
a
can
means
afford it, but it will
that it will increase the utility (welfare) of the
probably reduce the utilit of the larger
group
rhat knows that a life-saving technology is available, but not to them. Thus,
on markets may decrease social welfare for the society as a whole. If
.5
3.8
Slovak Republic
Slovenia
few who
reliance
8.7
2.9
1.9
&
simultaneously. These processes cannot be separated.
oford to pay for it. This
9.1
8.8
4.4
objective for which
asrly therapy is developed that has been shown to reduce the risk of
10.8
10.8
10.1
7.4
desirable
a
evcloping a fatal disease, but its high cost means that only a few people can
1.8
1.3
consider whether this is
B r way of illustration, Rice (1997) presents an example in which a
8.3
Norway
Poland
Portugal
to
6.8
8.5
Japan
1.4
fails
should strive (Arrow, 1963; Rice, 1997; Hanoch
distribution deci
overall social welfare
is
to
government to intervene
life-saving technology.
7.2
2.0
t
10.3
2.0
9.6
n
n ocher matters concerned
with social welfare,
ecisions
7.0
6.8
7.9
e
cient to meet peoples needs. Rice argues further that in health care and
7.1
Italy
New Zealand
ents
Medicare, 2015) because economic theory treats allocation and
tors for Me
arion activities of the economy separately. Supply and demand are not
8.1
Netherlands
m
healch
10.2
4.5
Luxembourg
Mexico
253
go ch-claimed advantages of competitive markets cannot be fulfilled in
care (Rice, 1997; Bambra, Garthwaite, & Hunter, 2014; Canadian
Total
Israel
Sorea
and Health Policy
Markers
health
Country
Private
Canad,
improve,
to ensure
it
might
therefore be
preferable
that all citizens could have
for the
the
access to
Privatization in health care has returned in the health care debate because
market mechanisms generate distributional advantages for some powerful
6.7
(Evans, 1997; Rice, 1997). This occurs in the following
way: first, a more expensive health care system produces higher prices and
incomes for providers, such as physicians, drug companies, and private
interests in societies
11.0
9.9
8.7
6.3
9.3
insurers. Second, private payment delivers overall system costs on the basis of
7.6
with
2.5
8.8
without having to support a publicly funded health care system for those with
2.5
8.9
Ower
9.1
7.1
1.7
3.8
10.8
income to ensure they have access to
quality health care services. Evans
997) argues that there has thus always been 'a natural alliance (p. 427) of
10.9
Cial interests between service providers and high-income groups. These
3.9
1..0
4.9
SES have a strong incentive to advocate market mechanisms in health care.
1.5
8.8
8.5
16.4
7.3
Co-operation and
Retrieved from htp://stats.occd.org/index.aspx?DataSerCode=HEALTH_STAl.
Development. (2015).
use or
at
expected
use
of health
care
services. If
people are charged for services
point of access, then the government contributes less. In effect, income is
redistributed from low-income
higher income
can
people to high-income people. Als0, people
purchase better access or quality for themselves
n
addition, only those who can afford to pay for
private care will jump
ueue and go to the private system, while those who have low incomes
statistia.
remain in the public system (Rachlis, 2004; Canadian Foundation for
Health Care
iees reduced
Impr
provement, 2012). Inde
the utilization of
care
health
research evidence shows that user
services when people needed c a r e
Healh Policy in
254
they led
in short,
user
fees in
reduced
to a
by almost
services
use
6 percent.
In
of eftective
that
showed
Saskatchewan
Rescarch
care.
on
particular,
families
used
families usd
low-income
me
public
system
private
do
hca
physician
doct
10
period,
activity,
private sphere.
with a
activity coexists
of the
social-democratic conception
private
involvement in
in which
a
Ihe mixed
economy
public policy spheres
such
as
they
firms. Their mandate
is
are
largely prohibited
for both
from
care.
froma
state
and
Leys (2001)
expand
health
markets
care.
of public
equity in
access
the market distorts
line rather than
bottom
the focus the
(1988, 2012)
by making
argues,
quality care.
importance of the public
to
The rise in
to
pressured
Leys notes that an important
such s
non-market spheres,
is to move into previously
the noton
As Stone
service
service, not
firms
strategy for
increase market share.
to
or
sector as
a
site for
achievimg
nal
s e r v i c e s
education,
and
housing. By opening
up the
sector as a
nas
rhev must have been employed, and the employer must have provided
benefits. As a result, many Americans did without health care
because they were either not employed, had employers who did not provide
health benefits, or were unable to afford either insurance or care. In short,
health care in the US continues to be market-driven. As noted in previous
chapters, Obamacare achieved "universal insurabiliry" (Hall &Lord, 2014,
P.3). Americans must purchase health insurance from the private health
insurance industry. Insurers cannot deny insurance to anyone or refuse to
health
cOVer pre-existing conditions. Obamacare, or the Affordable Care Act, did
not
socialize health care or payment.
numbers of studies are
t
finding growing dissatisfaction among
prOviders, as well as consumers, with the health care market approach in the
result ot interna
the decline in manufacturing as a
& Bambra,
Schrecker
competition (Price, Pollock, & Shaoul, 1999;
sector, includs
service
the
see
now
Thus, US and European corporations
increase the privatc
has
care services, as an alternative source of profit. To
state
the
vhich
in which
areas
ealth
Sector, however,
up markets in
requires opening
previously had responsibility. These areas include public services s
ro the
increasing
investmen
been attributed to
care,
on the basis of need, as it is in Canada
public health care system.
means that individuals are reliant on their incomes
and the market to obtain a service, such as health care. In the US, prior
implementation of Obamacare, employer health benefits were the
means to health insurance for most Americans; to obtain health insurance,
a
Commodification
behaving
public good
incomes to obtain a service, such as health care. In other words,
countries with
and other
to
to a
to ensure access
depend
health care is a public service provided
was a failure
recognize
notion of a mixed economy
that a flaw in the
argues
survival is threatened, firms
their
When
of markets.
the inherent instability
and their market
increase their market
seek strategies to
in the private sector
not contend with
do
sector, or Crown corporations,
share. Firms in the public
like private
this imperative, since
decommodification,
are. Decommodification refers to a state in which individuals are not
ianton theiri
economy is derived
health
and
market-derived incomes to obtain specific goods and services, such as
have had a nix sc
public sphere of economi
that allows
commodification
ommodificatio
countries
industrial1zed
on
on their market-
TO MARKETIZATION
economic
private
and
public
moOst
elaborates
chapter
While
cents have
have relevance for understanding health care market issues.
these concepts
Andersen (1990) devised the concepts of decommodification and
to
termine the extent to which individuals must
adians.
ting for
Since the postwar
ervices. Thus begins the process of commodifying services that were once
ublic services as a matter of right to citizens of a country.
C O M
2009). Allowinga parallel private system to coe
CONTRIBUTING
255
cOMMODIFICATION AND DECOMMODIFICATION
in the
benehts
(Rachlis, 2005; Canadian Foundatic
Improvement,
Health Care
the best interests of most Canad.
will not be in
system
alongside the public
since those waitine
times in the public system,
wait
reduce the
Nor will it
consider private care.
to
aftord
cannot
system
care in the public
FACTORS
Policy
deemec
care with higher incomes and other
system
public
in the
provided
not
to
health
and Health
ric and foreign corporate entities to create private clinics or other for-pront
the impact of
.
they lowered the annual use of phys
t
less (Beck & Horne, 1980).
almost 20 percent
services
could entice
that the private system
concern is
A further
Markets
Canada
allows
ecent
interview study of local health
doubted the
care
leaders in the US found that
E
capacity of market-based reforms to improve the ethciencyY
uality of US health care (Nichols, Ginsburg, Berenson, Christianson, &
ey, 2004). Many of the respondents appeared to reluctantly accept that
intervention may be necessary to improve care. A recent survey
Cnt
of adul
US and 10
t
the
comparison nations was carried out before the
provisions of he Affordable
Care Act came into effect (Schoen, Osborn,
Health Policy in Canada
Markets
and
Health
257
Policy
256
likely
more
The results
Doty, 2013).
Squires, &
s h o w that
Ud adults were considerals
do withour
countries to
in other
than their counterparts
A m e r i c a n respondents
the cost.
because of
were
more
like
kely to
ealth insurance. This study found
with health
for care,
difficulry paying
c a r e and contributing to E
report
in
deterring
inancial
role
have a larger
that costs
for those withour
health conditions than
these
chronic
those with
stress for
as well as the US. Seill
he
Canada, and Switzerland,
Australia,
conditions in
43 percent of those with chronic illness
health
care
even
d
high;
US responses are especially
two-thirds
costs. Also,
without care, citing
2013).
costs (Schoen et al.,
because
ofhigh
of
respondents did
market forces into
not
health
seek
care
could
in the Canada Headth
care
context, allowing
In the Canadian
medicare as specified
violate the principles of
well
very
in
chapters, directing public revenues to
discussed
previous
Act. In addition, as
but perhaps the spirit of medicarc,
letter
violate not the
private entities may
and
financing and administration
particularly with regard
of the health
have a
care
universality
public
of where they live in Canada,
system. All citizens, regardless
heath
Some
need.
argue this calls for
health care on the basis of
Box
8.7),
administration
(see
financing and public
have
services to
public
wynne's Spin
on
made lae
wneu
news
own
anges
10
from the ministry's
will implement cs
Care
Long-Term
and
and
fees
pay"rght
Ministry of Health
changes to
for the
These include
Or how about
this
one,
ymens
possible
Doctors
so
unt
payments.
physician services
patients that
that
Ontarians are paying
able
will still be
they feel
are
to
provide
required.
the
right
amount
any
Hoskins?
explain how cutting
$580-million
from the
theit
services
In my
exper
y
at
care
never
for
services
al
and all
work, Mr.
how would tha
While youre
Oh, really? And just
less.
is always
m o r e . Less
health
less is
could possibly have
come
up with such
a
harebrained scheme
to
manage
our
No wonder our patients are so confused. Someone clearly isn't telling he
a little reality check:
truth. Time for
There are approximately 12,600 general practitioners in Ontario,
14,500 specialists, 6,500 residents and 3,400 medical students;
Breaking those numbers down by gender, there are almost 17,000 male
and slightly more than 10,000 female doctors. Average age is 51.3
years;
Tuition for students
entering
their first year of medical school is
ypically $21,863-a 339 per cent increase over tuition in 1997;
eight to 12 years to become a doctor-a minimum
undergraduate study at university, three to four
a
teaching hospital or clinic;
complete a minimum amount of continuing professional
comments
wherever
with
Doctors must
those
war. Take
the first casualty in
Long-lerm
They say that truth is
of Health and
Ontario's Minister
Hoskins,
Eric
2003,
Dr.
week
last
by
cent since
have risen 61 per
that doctors' salaries
misleading-Onu
Care, suggesting
claim so fundamentally
over. It is a
took
Liberals
the
the ministersmott
it calls into question
release:
do not equal salary-that
services.
one
years of medical school, followed by two to five years in residency in a
The Globe and Mail
to
Matthews. No
health care system.
of three
years of
the Facts
The
Board President Deb
an ounce of common sense-not to mention years of medical training-
On average, it takes
Supported by
Ontario Doctors Not
By Douglas Mark
billings
clearly
Kachleen Wynne and Treasury
care
right to
Box 8.7:
to
to help improve the care our patients receive? If
rhreatening to do-is going
Houdini.
than
youre better
you can,
Dr. Hoskins who, after all, is a colleague, and who
Srill, our beef isn't with
in
a dificult spot. No, the real culprits here are Premier
himself
finds
thr
it,
o
u
budget-
o
u
this into
context,
Ontario's
r
that's almost the entire
population
population of lceland;
grows by 140,000 patients per year-again, to
put this into
context, that's almost the entire
population of Prince
Edward Island;
ne
number of seniors
in
our
province
is
growing every year,
puting
more pressure on over-taxed health care
erhead-the cost of actually running apractice, system
including staff salaries,
3pace medical supplies and ofice supplies-cats up approximarely
per cent (or, on
average, $130,000) of gross annual billings;
n doctor in
an
in their
.
could
y
development courses and training throughout their careers, in order to
maintain their license to
practice medicine;
Ontario's nearly 28,000 doctors treat
320,000 patients per day-to put
Ontario contributes,
on
average, four ull-ame jotbs
$205,000 in GDP for Ontario's economy, and
S50,000 Community,
in tax
revenues, spread out over all three levels of government.
Health ro11cy
258
in
Markets and
Canada
king
Those are the facts. An inconvenient truth for the Liberal governmen , I
brings
Dalton
under
Over the past 11 years,
billions of our
blown
have
Liberals
tax
McGuinty
dollars,
to
dig their
month,
youve
been reckless
noney
the end of the
at
status
to
Source: Mark, D. (2015,
be
sure.
But
on
Ontario doctors
not
the
supported by
from www.theglobeandmail.com.
facts. The Globe and Mail. Retrieved
THE IMPACT OF PRIVATE
POPULATION HEALTH
HEALTH
also have the
potential
to
developments
could
heighten inequalities
(Coburr
That is,
people
with lower social class,
occupational
Davey Smith, 1999).
While it has been argued that all countries show socio-economic
differences in health status, income and wealth gaps among Canadians have
been widening since the 1980s (Yalnizyan, 2000; Broadbent
Institute, 2014).
Much of the cause of chese growing social
inequalities has been attributed to
Canadian governments withdrawing from numerous
programs that provide
Canadians with income and employment
security (Scarth, 2004; Stanford,
2004; Banting & Myles, 2013). These
developments have been marked by the
increasing influence of the market sector in Canadian society. And evidence
from the United
Kingdom indicates that such increases are good predictors of
hardly surprising
January 19). Wynne's spin
poverty. Such
(Davey
Smith, 2003; Romanow, 2002; Raphael, 2008; Gordon, Shaw, Dorling, &
Ms. Matthews.
Disappointing,
in
income and wealth have poorer health status
compared to those
higher up on the class, occupational, or income ladder. This relationship
is one of the most robust findings in the health and social sciences
money.
landlord is
The
living
crarus, or
afloat
or
who are
health outcomes.
were
much what
facing
Because that's pretty
thanks to the Liberals.
we've got nothing for him,
and
knocking
After all, the only thing we do is keep
doctors.
the
blame
So go ahead and
mention nothing of working overtime to
save lives. To
people healthy and
our leaky health care system
shorten waiting lists, and generally keeping
truth.
you won't get from either the
Something
That's not spin. It's the plain
Premier
those
reported in the tamous Black Report and revisited in The Health Divide
Townsend, Davidson, & Whitehead, 1992). Research-since replicated
times-has shown that social class is strongly related to health
aumerous
im
200
out
with your
here in Ontario.
were
259
that are knOwn to determine
in living conditions
health. As background,
during the 1980s, class-related differences in health outcomes in the UK
way.
another. All this
up
of one boondoggle-or
for a lot of healthcare.
adds up, and could've paid
have to remind you what happens
Now, I'm sure I dont
and
when the rent is due
poor-or
accentuate unequal
Wynne. th
the
and Ms.
trying
one scandal-after
cover
Policy
Market approaches
nonetheless.
know. But the truth,
us to the consequences.
which
All of
Health
growing health inequalities (Shaw, Dorling, Gordon, & Smith, 1999).
In
Canada, research into health inequalities has focused on how
ON
CARE MARKETS
life
apectancy and the incidence of various chronic diseases, such as heart
he
Case and diabetes,
measures of
population health differ among8
pulation groups. For example, a 16-year follow-up study in Canada
on
ar
as
The creation of health
approach
increasing
to
health
care
care,
as
commodification
individualized
inaiv
markets is consistent with
tandem w
s
discussed in chapter 2. In
an
approaches
to
of health
health,
care
empl
individual mu
services is
in which the
an
havinga
her or his own health by making proper lifestyle choices, suc
alcohol
only
and
moderately
e c t sthe
diet high in fruits and vegetables, consuming
re
health
commodification of
getting regular physical activity. The
tne
infuence of neoliberalism, a political ideology that posits
r k e ta sb e s t
1
a
r
y
for allocating and distributing resources.
In addition, as stated elsewhere, one of the primay
creating private health care markets is that they reduce acc
th
particularly for vulnerable populations such as those wiu
a
e
c
c
e
n
c
e
r
n
s
a
b
o
u
r
ca
health
to
s
s
o wincome-
for
causes
age-standardized mortality was strongly
correlated with incomeexamined,
(Tjepkema, Wilkins, & Long, 2013). The lowest
incor
guintiles had the highest mortality for all causes compared to highincor
ne
Life expectancy for men who reside in the poorest of
Montreal'quintiles.
s health districts
iss 13 years less than for men residing in the richest
districts of
ce de la santé et des services sociaux de Montréal,
2007). MuchMontreal (Agenc
is
the
that approximately half of
have incomes below
Montreal
health districts in
d s low income cut-of. Wilkins has documented profound
in mortality rates trom a variety of aflictions as a function of
lation in othis
the
explained by the fact
Staristics Canada's poorest
low
diffex
average neighbourhood incon
Be
(Wilkins, Berthelot
&
Ng, 2002).
Health Policy in Canada
260
There is little doubt that increasing the role of the market in Cancocicty
tends
to
be related
to
2000). Wilkins documents
to
diabetes, suicide, and
growing
social and health
that income-related
inequalities (Raphacl,
in mortali
due
are increasino
while
differences
deaths from mental illness
are declining (Wilkins, Berthelot, & Ng, 20021
differences in heart disease
Neoliberalism has been shown to foster higher income inequality (Kaplan,
1996; Coburn, 2000; Lynch, 2000.
Pamuk, Lynch, Cohen, & Balfour,
because neoliberal policies weaken
is
This
2015).
the
Schrecker & Bambra,
role in health and social services
welfare state by reducing the government's
have introduced
nations
and many developing
Most industrial countries
that result in reduced social welfare and increased private
neoliberal
policies
sector
involvement in social welfare
provision.
issue of markets and health is to consider
Another way to think about the
economies are dominated by the
whose
nations
political
the health status of
that liberal
state. Esping-Andersen (1990) argues
the
than
rather
market
United Kingdom, are
the
and
the
US,
Canada,
political economies, such as
while social democratic
on
more
receptive
to
public policy,
market infuence
have greater state intervention
status?
health
in service provision. Do these
infant mortality and
examined predictors of low
Shi
and
(2001)
Navarro
1945 to 1980.
OECD countries from
higher life expectancy in a compårison
indicator
of the general
a n important
Infant mortality has been identified as
overall wel
of
indicator
an
also
is
health status of a nation. Life expectancy
social
a
democrale
found that countries with
being in a population. The study
but were a s
care systems,
health
more
conmprehensive
had
not
tradition
only
life expectan
rates and longer
more likely to have lower infant mortality
nations, such
Norway, Denmark, and Sweden,
as
nations differ in
of
trends.
as Canada, showed opposite
More specifically, infant mortality in Sweden improved
Liberal naions, such
from
infant
16.6 per 1,000 in 1960 to 4.0 per 1,000 in 1996. In contrasts
7.8
fell
to per
in 1960 and
mortality in the United States was 26 per 1.000
per 1,000 in 1996. Canada's
rate went
1,000. These
are
relationships
co
from 27.3
ent
er
other
with
to
1,000
6.
inter
s o c i a l :and
comparisons. Increased market infuence is related to increase
they want
health inequalities. Ultimately, Canadians have to decide whetne ervices
markets to dominate in the organization and allocatio
ofhealth care s
i d y that
and other
health-related public policies. This
was a landmark
e
Cxamined
key health indicators among OECD nations.
in
chapter
9, the form that the
retects both
welfare
state
assumes
As
wi
d i s c u s s e d
countries
differ
n
different political
ideologies and different class s
c l a s s
s t r u c t u r e s .
and
Health
Policy
261
Markets
cATIONS FOR HEALTH POLICY
IMP
DEVELOPMENT
of n e o l i b e r a l i s m in Canada and other industrialized countric
rriCtured domestic policies, which has implications for health policy
Its strength as the dominant political
ideology refect
health provision
and
interests that stand to benefit from the shift to
influence of particular
the
and delivery mechanisms. This can undermine
eot-driven financing
dominance
The
he
infuence of other
lt
medicare.
means
society actors that wish to preserve and improve
some perspectives may be shut out of the policy
Civil
that
development process. Indeed, governments sometimes undermine or ignore
that challenge the dominant perspective (Rochon & Mazmanian,
The restructuring may undermine the ability of national
1993; Bryant, 2015).
and weaken democratic processes (Teeple,
to set domestic policy
governments
commitment to market principles and practice exemplified
the
2000). In fact,
is opposed to those of democracy. It has been argued that
he voices
in
neoliberalism
constitute two different approaches
this is because the market and democracy
the social distribution of goods
market
The
allocation.
signifies
to resource
seller (Teeple, 2000),
and services through an exchange between buyer and
in which citizens
of
to
a
form
refers
organization
while
political
democracy
deemed to have a role in political decision making. There is concern that
neoliberalism undermines citizen participation and the democratic process.
are
The requirements of economic globalization (to be examined in chapter 11)
invest greater power in transnational corporations at the expense of civil society.
CONCLUsIONS
Ine creation of health care markets is the desired outcome of those advocating
ncreased
privatization of health
care
services. The creation of
health care
S 1s driven by political ideology commitments to market-drivern policicsy
f e d by the economic interests of particular sectors. The establishment
emarkets has implications both for access to health care for Canadians
tnc
n the alocation of political, economic, and social resources among
pulation. The intellectual support for such developments- d l
isbased
where
conomic theory that stresses the micro-economics of the indiviauay
advancement and self-interest are seen as the driving forces
uman motivation.
The
health
O
nealth care
for
markets has special implications
access to
pecific groups in Canada, such as low-income populations.
Health Policy in
262
advent of
As such, the
health
care
of citizenship
therefore the
most
likely
from such
a
who
increase
rates
mortality
who
are
The creation
tied
to
as
usually
well
argue
capacity to set
nations
ma
of market approaches
provide health
domestic
2001;
policy and,
to
health
care
and
since provincial
services.
Kirby (see chapter 7)
which Canada is
Canadas
treaty
set
forth the
Aadersen,
Esping-Andersen,
on
Health
in Canada.
private
alternatives
could violate the
signatory
are
could make it
provide public
of trade between
may require
care
Mazankowski
and
by
trade treaties o
of international
In addition,
& Sinclair, 2004).
commercializimg
difficult
to
reverse
and territorial governments
in
What
is it about health
not
of the forces in favour of
Why might the public be led to
make it
a
typical com
care
privatizing health
health care
would
in
believe that markets
care system:
improve the functioning of the health
to consider
are governments apparently so willing
why
m a r k e t solutions
to health care problems?
proach to health
5. What would be the result of bringing a market appro
in
Few
general and to health care in particular?
three worlds
of welfare capitalism. Princeton,
University Press.
discussio
in modern socialsscience
of welfare
v
one
p
r
ovides
o
v
a
i
functioning of
contemporary
advanced
Western societies.
politics. London: Verso.
the key processes of the
a n original analysis of
This book provides
conversion of public-service workforces
the
services,
commodification of public
and the role of the state in
motivated to generate proht,
Levs, C.
into
(2001).
Market-driven
employees
absorbing risk.
and inequalities: Consequences
Navarro, V. (2007). Neo-liberalism, globalization,
NY:
Publishing Company.
Baywood
Amityville,
for healsh and quality
that
articles
of
series
challenge neoliberal
a
assembles
This book
articles
these
question each
ideology. Written by well-known scholars,
the
policies guided by
of the tenets of neoliberal doctrine, showing how
oflife.
this
diry?
W h a t are some
(1990). The
ideology have adversely
where they have been
that does
die.
have occupied as much attention
states in Western societies. Gosta Esping
the changing
as
contributors to current debates on this issue,
of the foremost
Andersen,
the character and role of welfare states in the
of the
n e w analysis
NJ:
future:
CRITICAL THINKING QUESTIONS
care
Princeton
G.
how ideas related to the value of markets in health
refuse to
monopol,
suppliers of health
recommended
terms
(Grieshaber-Otto
by several provincial
globalizatio
government
the sole
Policy Research.
nature
national government
terms
are
staf
development, buti
These terms
and
discredited yet
for f
care
to continue to
governments.
on national
care is a
commitments
reforms initiated
that
territorial governments
Some of the
isolated
undermines
in particular,
international agreements
Services
Health
shape health-related public nol
Teeple, 2000). Indeed, some citi
interferes with and
impose obligations
changes
not a n
care zombies: Discredited ideas that will not die. Vancouver: Centre
usses
for This report discus.
of less-experienced
to use
263
Evans, RG., Hertzman, C., & Johri, M. (1998). Lies, damned lies,
andh
hospitals co ared to
of economic
to the requirements
how these forces
health care.
Recent
is
care markets
responses
that globalization
L
ed with
2003, 2010). This burden tende
in their families.
primary c a r e providers
politics (Leys,
national
as
the
of health
government
chapters explore
Later
may be due
associas
(Armstrong&Armstrong,
members
women,
taged-and
the greate
by public systems
private, for-profit
Greater use
been
and have
provided
individual households to
on
the burden
increase
in
Ihis
hospitals.
Dublic, not-for-profit
staff complements.
reduced
and
coOsts
to care
olicy
FURTHER R E A D I N G s
Barer,M . L
Health care markets may
care as compared
generally inferior
higher
being arigh
care
Pol:
Markets
shift.
consequences
have found
are
such services-would suffer
need
to
f
shift
the most disadvar
markets would
Ihose
commodity.
to a
Health
and
Canad.
development
affected human
in the countries
implemented.
dchrecker, T, & Bambra, C. (2015). How politics makes us sick: Neoliberal
pidemics. Houndmills, UK: Palgrave Macmillan.
on neoliberalism
s book represents a new contribution to the literature
and its
impact on health outcomes.
Stuckler,
Why austerity killbcesions, budget battles, andthepolitics oflife anddeath. Toronto: HarperCollins.
The Body Economic provides hard evidence on the often tragic human toll
of the
D., && Basu, S. (2013). The
body
recession worldwide. From
a
economic:
rise in alcoholism in the UK
to
Chapter9
POLICY IN BROADER
HEALTH
PERSPECTIVE: WELFARE STATES
AND PUBLIC POLICY
INTRODUCTION
The form
that health
care
what
Canada is part of
1998:
Banting &
policy
and health-related
public policy take
has been termed the advanced
Myles, 2013).
The advanced welfare
welfare
state
state was a
in
(Myles,
significant
economies following the Second
development in most developed political
the Canadian welfare state as we know it today
World War. The source of
Canadians during the
in the insecurities and experiences of
can be found
the
and the Second World War (Teeple, 2000). In policy studies,
Depression
welfare state refers to a set of social reforms-such as public pensions, public
health care, employment insurance, and social assistance-implemented by
governments
to
provide
citizens with various supports and benefits. These
retorms are important because such policies have been shown to be important
predictors of the overall health of a population (Raphael, 2007b).
Rather than seeing the advent of the advanced welfare state as a reasoned
gOvernmental response to perceived citizen need, it has been argued that
l d d a it was actually a governmental concession to the significant and
20U0).
ncd calls for reforms by citizens and the labour movement (leeple,State has
C Welare state has been defined as "a capitalist society in which the
d inthe form of social policies, programs, standards, and regulations
certain
mitigate class conflict and
to
provide for,
answer, or accommodate
tor which the capitalist mode of production in itself
cas
solution or makes
no provision" (Teeple, 2000, p. 15).
Whateve
some security
atever the reason, as a
has
no
result working families and individuals won
A
unbridled operations of the economic system.
key
key guidin
of public
principle
behind
state is that the provision
the
welfare
Plogams
programs anand servi
rather than a commodity
a n entitlement of citizenship
services
Tequiring
against
the
carned
income. These various programs
and
Health Policy in
270
maintain
enabled people
dependent on their ability to
to
a
decent standard
of living thatthat
Policy i n B r o a d e r
271
was not
HISTORY
totally
man
and services come to be decommodified-that is, not subject t
purchase in
the open marketplace-a key concept in understanding the form and
earn
market income. In essence,
Perspective
Canada
welfare state
The
function
of the welfare state in nations such as Canada.
In Canada, the welfare state also redistributes economic
ces
high-income earners to low-income earners. As one example, the heal
and
WELFARE STATE
OF THE
refers
government intervention in
refers to
ar include education, social servicesthe provision of supports
such
raining, public pensions, social assistance, employment
and health care
1997). In addition to providing citizens
services
as
insurance and
with various kinds
of
of the welfare state also served as a
vehicle to promote
securitys
distribution and class harmony (Teeple, 2000).
Themodern welfare state as it evolved in Canada and other
from
(Banting
the
system is funded by general revenues received from citizen tayes (T. care
creation
esource
2006). High-income earners pay greater taxes in both absolute (dollar
relative (tax rates) amounts
(Murphy, Roberts, & Wolfson,
income earners, howeves, are less likely to become ill and make
use f the
health care system (Raphael, 2007a). Thus, the public health care svstem
2007). H
effective
is
very
is
means
Canada has developed a more generous welfare state as
compared to that
of the United States, but evidence indicates that it shows
greater similarity to
the US version than it does to the more
developed and generous European
standard in being what is called a liberal welfare state (Saint-Arnaud & Bernard,
2003). In Europe, two alternatives to the liberal welfare state emerged during
the late 19th and 20th centuries: the conservative and the social democratic
(Esping-Andersen, 1990, 1999).
Esping-Andersen (1990) identifies clusters of social democratic (Swedes.
orway, Denmark, Finland), conservative (France, Belgium, Germany, Ial
and liberal economies (Canada, Ireland, United States, United
Kingdom
Australia) that differ
of social provision. And thee
to be related to both the comprehensivene
system as well as the health of their populato
in their kind and
the
called
degree
The modern welfare state is often referred to as the Keynesian welfare state
(KWS), the name deriving in part from the economist John Maynard Keynes.
The principal asumption in his work was the existence of a national
economy
in which, he
argued, the State could intervene to influence levels of investment
and domestic
income, and
grants, and concessions) and of working-class reproduction (through public
works and forms of
income support), as part of a political compromise
working classes in an attempt to moderate the business cycle (to
a
repeat of the unrest of the 1930s), to help rebuild the war-destroyed
of
tain
diminish
ne
most
eveloped
examines
liberal welfare states-this has
been the case. This chapter
the nature of the Canadian welfare state. It considers how the three po
especially
politic
economy typologies of the welfare state, theorized by Gosta Espingsense
i
d
e
ensure
a
Drchdcw Deal, Keyneswrote:"Ifyou fail, rational changewill be gravely
nroughout the world, leaving orthodoxy and revolution to tght it
out" Donald
Winch
nch argues
argue that Keynesian policies were "an effective weapon
use
against
the
the one hand and the defenders of old style
Marxists on
capitalism
on the
other; real third
the
r
e
absence of which before
the
General Theory had driven manyalternative,
into the Communis
Pproach
s
Europe (to
the reconstruction of capitalism), and to
growing interest in socialism due to the expericno
1930s and the devastation
of the war. In an open letter to
or
a 1
care.
health
(1990), help to make
of how Canada develops and enacts
aPP
policy
this
of
public
health-related public policy. The consequences
are also
tor the health and
well-being of the Canadian population
thereby partially regulate unemployment through
national "demand management"
policies. Such intervention represented a
certain socialization of the costs of
production (with State credits, guarantees,
Es
n
point of his work was that the
Box 9.1: The Keynesian Welfare State
(Coburn, 2006; Navarro & Shi, 2001).
statein
0
both Canada and the United Statesboth already with relatively undev
The main
sodieral functioning and citizen well-being (see Box 9.1).
PCvEnt
Iet in every case, economic globalization has exerted powerful pressures
1995).
e chould intervene in the workings of the market economy in order to support
differences have been shown
of each nation's health care
governments, which has resulted in some weakening of the welfare
industrial countries (Banting, 1997; Banting & Myles, 2013; eeple,
developed nations
Keynesian welfare state, named after the economist John
Mvnard Keynes (Townsend,
of assuring health care provision to citizens as well asa
means of economic redistribution. Whether this latter
goal was an intention of
its creation may be uncertain, but it clearly serves these dual
purposes.
a
sometimes
d
.
Source: Teeple,
p:9).
0 0 ) . Globalization and the dechineofsocialvgorm Into the wensy-firstcenu
Aurora, ON:
Garamond Pres.
Health Policy in
Canada
272
world wars increased
and the two world
of the Depression
The expericnces
more
security and protection
demands for
working-class
and the market's deleterione
downturns
of the business
personal well-being. Many
from
t's deleterious effects the
cycle
citiens
came
to
believe that the
dominance
o
that it
benefitted
had
of the market economy
the
of the mai
expense
the
wealthy-at
business and
owners of
demonstrated
class
working class to reconcile the
between the market
in its most extreme forms.
especially
business
cycle,
effects of the
Box 9.2).
(see
1930s
the Depression of the
the
Perspective
273
st-Second World War welfare state was also intended to help rebuild
the
amaged economies of Europe.
war-damaged.
By doing so,
economic
system and
War
these social and economic retorms were
(Teeple, 2000). Thus,
the inequalities and insecurities created by the market
a m e l i o r a t e
n.
t
at the same time preserve the market economic system that produced these
The development of the welfare state-its specific social reforms and means
nations in time and circumstance.
af implementing them-differed among
Ear example, Sweden, an exemplar of the social democratic approach, began
German welfare state,
an
the 1930s
cxemplar
(Esping-Anderscn, 1985).
of the conservative
early as the 1870s. The liberal welfare state-always
Definition
cycles are periodic swings in an economy's pace of demand and
production activity. These cycles are characterized by alternating phases
is
of growth and stagnation. A period in which real GDP is rising steadily
called
is
called an economic expansion, and a period in which it is falling steadily
a recession, is called an eco
a recession. The carly stage ofan cxpansion, following
of the natural ebb and How of
nomic recovery. Although these cycles are part
Business
economic activity, their length is difficult to predict.
dircct impact
social democratic and conservative nations-showed its greatest development
during the post-Second World War period. It was only during this period that
Canada and the UK began to implement universal, publicly organized health
care. In recent years, liberal welfare states have been particularly susceptible to
market reforms (Swank, 2010). Chapter 8 explored the impact of markets on
the health care system.
Canadians. Periods
of economic
0u
Slowdowns in the economy
theoretical frameworks have been developed to understand the
Characteristics of different welfare states and the influences that shaped their
cvelopment. Typologies arrange national welfare states into categories or
Lsters on the basis of one or more characteristics. A limitation of typologics is
mask important differences between
may
be in the
same
category (Olsen, 2002).
ne
to
Examples
Canada in
cconomic contraction
the
experienced in
has also hadt
Canada
1930s.
1990s. In the
Depression in the carly
century was the Grcat
1982 and in the carly19905.
serious recessions in more recent years-in
healthy
a period of
2000s, Canada experienced
late 1990s and
conomic
coe
carly
Cxpansion and prosperity.
fromww
OurCe:
The
Levnomicconcepts:
a(vernment of Canada (2008).
canadianewnomy.gc.Ca.
as
undeveloped compared to
Various
boom
economic prosperity.
bring jobs, growth, and
out of work
the other hand, hurt businesses and put pcople
The most serious
The
approach, began
THEORIES OF THE WELFARE STATE
How Does It Affect Canadians?
cycles have a
meant to
economy,
insccurities.
a
Box 9.2: The Business Cycle
Busincss
repaired and preserved
arose
ro build its welfare state during
on
it
restrained growing socialist
activity that first
the
during the Depression and continued to grow during the Second World
capitalise
welfare state emerged as a political compromise worked out hy e state
sector and
in Broader
Policy
Health
businesycle,
cycle.
Retrieved
Ketticveu
such
nations that
at
fhrst
appear
typology dichotomous. The dichotomous typology contrasts
betwcen the residual
state and the institutional welfarc state (Olsen,
2002). "The residual welfare states
are less developed and provide a smaller
welfare
range of social
wclfare
hcome replacement
is
These include less generous bencfits and lower
on job loss or acquiring a disability. Overall, levels
casures.
of social cxpenditures are lower as npared to welfare states characterized as
insitutional.
sidual states
target bencfits
criueria are stringent,
ngent, and there
at
the less well-off in
are
usually
a
a
society. Eligibility
multitude of rules
and
274
Health Policy in
Canada
obligations that include means testing (Olsen, 2002). Means
Means
requirement in which appiicants ror income supPort such as socialtesting
is
must
are
demonstrate
approved,
benefits
are
a
other income.
9.3:
Once
nce benehts
are
constructed to
widely.adopted typologies
Thefirst
various nations
policy orientation
In contrast, an institutional welfare state does not treat
public wel C.
programs as last resorts for emergencies or situations of urgent need (O
2002). Institutional welfare
state
social assistance
benefits
etween
and
citizen-entitled
serie
rvices
levels
state
easily accessed than benefits in a residual welfare system. The insticutiona
approach sees allowing the free market to allocate resources as an inferior
means of addressing many types of social need.
caregory. For example, the residual welfare states of southern Europe-
Greece, Italy, Portugal, and Spain-differ from the English-speaking residual
states-Canada, the US, the UK, and Ireland. The binary ypolog
application,
different types of welfare
provide a starting point
comparng
and
has ben widely applied
t
& Bernard, 2003).
programs
Supporting latc t
welfare state regimes
lex of interrelate
actually complex
organizational characteristics.
In essence,
the term
capitalist societies signifies the
weljare stra
of features
by which
and
i
n
d
u
s
t
r
i
a
expenditrure. And since residual welfare
or less well off, far fewer people are
poor
benefits
largely on
the basis of demonstrated
welfare state is premised on the notion that the market (and, to a lesser extent,
the family) is the "narural and best means for meeting the needs of citizens.
considered
substitutes
when
temporary
measures are
only supplementary, serving primarily
private welfare channels break down or are
to
be
institutional welfare state model, in contrast, does not treat
public weltare
PIOgrams primarily as a last resort to be activated during periods of emergency
and
urgent need (interruptions in earnings due to illness or
for
unemployment,
cAample). Rather, they embraced
important first line of social protection,
oCn
emphasizing
rather
than
prevention
simply reactive remedial measures.
Ih
market, in turn, is considered be largely inferior way
of addressin8
ntypes of basic human needs. The character of institutional welfare
states
as an
or
to
a
ands in stark contrast to those categorized as residual; benefits and services
cover a wider
range of contingencies, are more generou and of a higher quality,
and are
more
easily accessed.
l
in
i t i o n sd e h n e
major insti
targeted
at the
is also a very high social stigma attached to many of the benefits provided
by residual welfare states. Best represented by the United States, the residual
a
set
are
are
how health care and
icies developed
health-related policies
u
and how such
1990) considers whether policies can be influenced. Esping-And
the
ood by analyzing
a nation's social policies or by welfare state is best understood y t shape
these collections of
the
examining
institutional forces
a
he
nation's social
the
argues that
policies.
the later approach,
are
state.
Ihe
WELFARE CAPITALISM
critique (Saint-Arna
lower levels of social
otherwise unavailable.
ESPING-ANDERSEN: THREE wORLDS OF
why and
welfare
maintain other stringent eligibility conditions,
need, these programs typically
relatively long qualifying and waiting periods
and
including
obligations,
rules,
s
sheds light on
in Canada
detail and classify the social
dichotomous, distinguishing
es of welfare provision: a residual welfare state and
institutional
eligible for benefits. Allocating
Public
states.
Esping-Andersen'
s three-welfare-state typolo
is also the
subject of much
often
a
before benefits may be accessed, short periods of benefit entitlement, and
there
Not
surprisingly,
variety of grounds for disqualifying benefit recipients.
Olsen (2002) identifies a limitation with the binary residual-institutional
approach, as it can lump very different kinds of welfare states into the same
for
of
major ideali
comprehensive
Considerably
range of contingencies, and are more generous, higher quality, and more
but it does
more
two
were
.
wider
welfare
has limited
versus
less comprehensive; they have a much narrower
Residual welfare states are
and cover tar fewer social contingencies
social weltare measures
range of
also provide more modest benefit
han institutional welfare states. They
rates and, consequently, are characterized by
and income replacement
a
n,
social protections and social
investments. The
general approach is one of promoting well-being and preventing problem
rather than providing services and supports on a reactive or
remedial
basis. Benefits and services are more comprehensive, covering a
are seena
welfare State Typology: Residual
I n s t i t u t i o n a l
state
commitment to reducing poverty.
275
Perspective
Box 9.3:1
waiting periods before they are
provided, and
provided for short entitlement periods. There is litel hese
there
then
they
have little or no
Broader
Dichotomous
social assistance
.
that
in
Policy
Health
ource: Olsen,
G.
(2002).
The
polizics ofthe welfare
state
(pp. 69-70). Toronto: Oxford University Press.
276
calth Policy in
Canads
socialism.
to particular aspects of their contemn
mporary
social policy approach as well as their broader political and economic
eatures
(Arts & Gelissen, 2001). The form that weltare states assume in difesrent
and political ideology.
shaped by economic interests
does not explicitly discuss public health. It should be
Esping-Andersen
countries is
embraced publie
health refers in this volume t
Public
health
inequalities.
concerns with
determinants of health by public policies that reduce
addressing the social
The result of this work
was
Esping-Andersen's
of Welare
typologies
Tbree Worlds
liberal, conservative, and social
These patterns-based on the
their established patterns of welfare provision.
the mi
the market, and the family-specified
interrelationships of the state,
civil-sector soca
and
each nation provided of public-sector, private-sector,
state.
identified as a liberal welfare
is
Table 9.1:
The
have
1990). His three welfare state
Capitalism (Esping-Andersen, democratic-classified
nations on the basis of
programs. Canada
squarely
Social Democratic
Australia
Belgium
Denmark
Greece
Canada
France
Finland
Ireland
Germany
Norway
Italy
Portugal
UK
Netherlano
Sweden
US
Switzerland
means
means
1990). As
a
term
economy,
with the
liberal
which
signifies
its
principles
embodies
of
early industrializing capitalist
American usage
as
being
laissez-taire orientation
a
nations.
somewhat more
It does
progressive
not
associated
refer
to
the
than those who call
nations in
argued that the conservative
in their
are actually more progressive
below)
(see
Esping-Andersen's typology
are also rather
nations
Liberal
nations.
liberal
than
provision of social security
themselves
more
conservative. lt
be
current
neoliberal
take up policies considered to represent
of the distribution of
emphasis on the marketplace as the arbiter
likely
thought:
can
to
resources among the population.
While
even
liberal welfare
wel-off to the less well-off in
states
a
redistribute economic
resources
society through progressive
from the
income taxes and
is
operation of public health care systems, the extent of this redistribution
Consistent
2001).
&
riess than in other welfare state types (Navarro Shi,
with this, benefit levels tend to be low. The chief objective of this form ot
is to help address the needs of the least well-of, but there is litle
the disadvantaged for their past experiences or protect
compensate
O
Latin
Conservative
of
ot
the
Welfare State Regime
Examples of Members of Each
Liberal
form
form
individuals
political
mobilization and political philosophy: conservatism, liberalism, and s0cia
inequalities.
r
or income testing to determine eligibility
result, social assistance is usually provided
(Esping-Andersen,
This type of regime provides basic social safety nets,
least well-off.
onlyto
who are unable to compete successfully in the
reliet for
minimal
or programs as a right of citizenship or national
benefits
few
markerplac, a n d .
sidual approach to social welfare based on the belief
a resid
It is clearly.
residency.
will prefer to depend on
benehts are too generous, recipients
har when welfare than seek out employment for earned income. For Espinghese benefits rather
Australia, Canada,
the liberal weltare state is exemplified by
Hersen (1990),
Anders
the United States, and the United Kingdom.
Zealand,
Ieland, New
historical roots in 19th-century political
some
some
with
done
into three distinct groups (Esping-Andersen, 1990). The distinguishinefe
social
e
most undeveloped form. lt provides modest
fare state is the
social-insurance plans to citizens, which is usually
of these nations was their identification with three specific traditions of
poverty and
d
sal transters and
typology did not comprise a large number of cases, they did distinguish th at
states
a
The liberal welfa,
At the time of his initial development of the three ideal welfare s
Esping-Andersen recognized that while societies he included in the
democratic weltare
o
Liberal Welfare States
marke
noted, however, that social
r
Health
social citizenship and provide welfare. The major institutions of th
he
and the fa nily have unique
economy, the state,
interconnections that Can.
different forms (von Kempski, 1972).
take
These features were linked, he argued,
277
Broader Perspec
Perspective
B
in
P'olicy
tedisteibution
furure hardships. Benefits
from
the
to
are
best seen as being
residual concept of the dichotomous
typology.
oflast resort, similar
Spain
Conservative Welfare States
. 52
fwelfare capitalism (
Sources: Adapted from
Esping-Andersen, G. (1990). The three worlds of We
(2003).
Princeton, NJ: Princeton University Press; Saint-Arnaud, S., and Bernard,
nard, P.
countries. CureI
resilience? A hierarchical cluster
in advanced
advanced cou
analysis of the welfare regimes in
Convergr
Emes
515), 499-527.
servative regimes are characterized
or
sometimes
paternalist
by
authoritarianan approaches
appr
that historically have had strong ties with the Church
Esping-Andersen,
either
Crsen, 1990). Examples are Germany, France, the Netherlands,
2/0
calth Policy in
Beleium,
Spain,
and
ltaly.
ESping-Andersen
"statis
because of their
"corporatist"
and
Canat
Anada
Health
nations as
traits
The
(1990, p. 27).
h
other words, conservative welfare states are structured to maintai
reproduce
classes
wealth among social
las
sectors. There is rather little commitment to creating an egalitarian.
the existing
income, and
differences in status,
&
rd,
a
social
td
terent sectors
social
more
rovided vary by
generous payments.
opposed
to
social
sector,
with
universal measures.
or
the life cycle of a single
available in old age or sickness,
individual
over
or
family
during periods
or
portant
higher-paid employees receiving
Conservative welfare states
assistance
part
of
stress
social insura
They redistrih
to ensure
that
In social
The conservative
on
the
family providing
exhausted its
own resources
state
income
for taking
care
of family
as
members.
Family benehu
promote traditional motherhood.
The
conservative
1990). In this
sense,
highlights
with
disposition
Christian
norms
the
to
welfare state (Esping-Andersen,
conservatism,
relates to classical
word conservative
community,
which
a
regime is also a corporatist
resist
and
authority, hierarchy,
change and
and traditional
preserve
family roles
are
radition,
states.
promote
providing
the
of
orientation
is preventative. An
problems
equality and
toward social
to
The
eliminate poverty
income.
distribution of economic resources, including
and
tull employment is a key priority,
democratic regimes,
together
values,
traditions and societal
market
than the
m o r e central
focused
1990). In
(Esping-Andersen,
is
unemployment.
characterized
is
regimes
approach is
labour policies
.cr
a
t ie
ve
retaining Status
but with less emphasis on the marker and
classes,
social
differences berween
of weltare. The Church has a prominer
commodification as the providers
o
r
corporatist weltare regime, with emphasi
conservative
role in shaping the
traditional nuclear family. The emphasis i
the
and promoting
on the family
when the family has
social welfare. The state provides
weltare
of the liberal welfare
through more equal
a
SUunn.
t
of
f the
strive for far-
states
conditions rather than
optimal
to
tic welfare
d e m o c r a t i c
of the economy. These are fhinanced primarily by employers and worke
benefit levels
closer
haracteristic
basic minimum cha
welfare
democratic
welfare. The social
hing objectives
members of die
social insurance programs for
Ber.
geted social
Conservative welfare regimes use a range of separate but state-n
and state-directed
Perspective
that emphasize
weltare regime comprises nations
sOcial democratic
(Saint-Arnaud
social
of
decommodification
rights
universalism and
the
lism and the
universal rather than
other words, the state provides
In
2003).
considers these
organicist
Broader
in
Policy
on
employment
training
are
extensive
Canada and
regimes such as
the result
active labour policies,
to have and
more
liberal
contrast,
less commitment to
IUS have rather
are
likely
with high education
workers
is that
with less education
those
than
af which
opportunities
and training
have m o r e insecure
take educational
2006). Liberal regimes
Broucker,
de
(Mvers &
tew o r n o benefits.
that provides
employment
the provision of basic
social democratic regimes is
of
then,
The key feature,
comprehensive health
ciizen
entitements, such
care,
safe working
ied
to
infation
environments, and
to
keep
policies
to
Such regimes are similar
as
both
retirements. Pensions are
regimes
training
that promote
labour market
welfare
secure
a
social
usually
the poverty line (Espingolder citizens well above
active
also tend to have strong
democratic
Andersen, 1990). Social
workers.
well-paying job,
as a c c e s s to a
right
and
retraining
institutional welfare
and social
states
programs
that
see
tor
citizen
investment.
DECOMMODIFICATION AND STRATIFICATION
ocial Democratic Welfare States
Esping-Andersenis
tnat
provide
p
broad and extensive programs
ocial democratic regimes have
(Esping-And
citizens
urity to their
economic and other forms of
typology
is
based in
large
aecommodification and social stratification within
he
degree of
sociery (Arts
& Gelissen,
part
a
on
2001; Esping-Andersen, 1990).
programs are compulson
1990). For example, many social-insurance
high employment
workplace, which,when combinedwith traditionally
programs and beneht.
rleveks
e v e k s
Access
programs an
provides a very developed welfare
and
are based on a record of contributions made by employers
em
state.
to
ts
end to *
Even when such contributions have not been made, benci providedbr
comprehensive. Coverage is strikingly more developed than tna
liberal regimes.
Commodification and Decommodification
employecs.
On
are dependent
the degree to which citizens
and services.
goods
arket and earned incomes for the provision of are not
depenaen
Onmodification refers to the degree to which citizens
modification refers
to
Hcalth Policy in
280
lealth Policy
Canada
in
Broader
Perspective
281
SEFULNESS OF THE ESPING-ANDERSEN
these goods and
their market incomes-or wages-to
services.
as a matter of righr (B.
is
it
decommodihed,
provided
When a service is
such
as
services
education, child
other words,
Andersen, 1990). In
at
care are provided by the state in a "
training. and health
obtain
on
WELFARE TYPOLOGY
Esping
employment
that coexists alongside
illuminate
concepts that
economy"
powerful
social welfare provision.
have strong
in addition
the
the
private capitalist market.
role of the state versus the
These concepts and how
implications for the development
traditional health
to
care
rhe
"public
nese
Since
a
maren in
they play out in
services.
nation
a
of health-related public
policies
n.
Stratification
(p. 55).
which
existing patterns
the kind and
occurs
of inequality within a country,
divisions, and
of social solidarity, class
degree
through shaping
status
maintains and reinforces
diferences
existing patterns
welfare state
For example, the liberal
intervention in the workings of
is rather little state
there
of inequality, since
commitment, for
or ideological
institutional
little
the marketplace. There is
assistance
programs are
social
eliminate poverty. Hence,
the
c o n t r a s t s with
example, to reduce o r
This
households.
immediate needs of
intended to meet the
inequaliy
to
has a deep commitment reducingg
the
social democratic regime, which
committed to preserving
is
conservative
regime
use
and poverry. Similarly, the
families before they
the costs of family by supporting
and
socializing
to
tamily
conducive
reducing
an approach
their own resources. This is not
on ue
up all of
associated with being
it does blunt the rough edges
inequality, though
lower end of the status hierarchy.
impacts thereto
policies, and their
social democrato
liberal,
refiect differing national political ideologies:
this ypology Pro but
conservative. By highlighting political ideology,
policy
Health
care,
health-related
or
in
health
ctories
understanding not only national traject
ideology
political
as a
liberal
neoliberalism
of
thar
also the impacts of the resurgence
it has been argu
For
welfare
example,
but
not
some,
all,
regimes.
means
for
welfare regimes, already market-oriented, are more susceptibie
of neoliberalism and globalization on their policymaking
Banting & Myles, 2013). And, as has been noted, health
of increased market sector interest.
care
phael,
200%
y i so n e :
pony
of Tbe Three Worlds of Welfare
Capitalism, debates have raged
(2)
its
to
issues of
much overlap
was unfounded. Defamiliarization refers to
Esping-Andersen as gender-blind
are able to maintain a decent standard
families
rhe extent to which individual
defined the welfare state as a "system ofstratification
Esping-Andersen (1990)
ofclass and the social
are
states
key institutions in the structuring
(p. 23): Welfare
states to reinforce or reduce
This refers to the capacity of welfare
order"
publication
sensitivity
typology;
r(1) the accuracy ot Esping-Andersen's
the impact of economic globalization on the quality
and
(3)
der and diversity;
gen
of the weltare state (Kasza, 2002; Bambra, 2005, 2007).
foftthese different forms
to c o n c e r n s about the role of gender in
Esping-Andersen responded
Foundations
Social
of Post-industrial Economies (EspingLe1999 volume,
the issues
exploring
of female employment and child care
1999)
by
Andersen,
examination of the relationship
detailed
her
In
welfare
types.
three
among the
and defamiliarization, Bambra (2004) identified
decommodification
hetween
berween these concepts, concluding that much of the critique of
of living either through paid employment
(Lister, 1994, cited in Kroger, 2009).
or
an
income-support program
Esping-Andersen generally focuses on the nature of income and other
related financial supports as an indicator of the form of a welfare state and does
not relate the welfare state to health care. In many social democratic nations,
health care developed as an integral component of the welfare state. In liberal
nacions such as the UK, national goverrnments created a public health care
system before developing the other service components of their welfare state.
WELFARE STATES AND HEALTH-RELATED
PUBLIC POLICIES
aphael (2010)
recently compiled information on how Canada stacks up against
developed nations in terms of supports and benefits. His analysis sheds
t
ght on where Canada stands
as a
member
ofthe liberal welfare
stare
club.
Akeyaspect ofhealth-related public policy is degree ofsupport for citizens. ine
for Economic -operation and Development (OECD) calculates
Organisation
the
percenta of each country's gross domestic product that is transferred its
citizens. Transfers refer to governments taking fiscal
generated by the
to
marke
resources
cconomy and distributing them to the population
Supports, ornvestments
investr
as
services, monetary
includes
in social infrastructure. Such infrastructure
family
welfare
payments,
or
training, social assistance
education, employmen
Supports ployment
ensions, health and social services, and other benefits.
Health Policy in
282
Nations may
marketplace
may
to
intervene
choose to
transter
choose to
decide how
relatively
small
economic r e s o u r c e s are
to control the
making authority concerning
and
Or, a
give itself nation
the natioecisionhs that
have less
these allocations. As itturns out,
r e s o u r c e s are more
a
Policy
allowing the
likely
to
of
greater proportion
better health status ar
lower poverty rates, and generally
inequality,
that transter less (see Box 9.4
to those countries
transter
Health
in Broade
Perspective
283
amounts, all,
distributed.
etplace
Canada
ng the
population compared
c
o
n
d
rich
i
t
Inadequate funding for education. A growing gap between the
poor. Reduced help for marginalized groups like "high-risk"
and victims of domestic abuse. One in six children living in poverty,
i
o
n
s
.
rhe
youth a
double that rate for Indian, immigrant and visible minority children. A
nd
deplorable lack
The simple
of affordable
fact is that
housing.
tax cuts
undermine the
government's ability
to
And this is exactly what the tax cutters intend. Tax cuts are an integral
act..And
aponent of
Services
Box 9.4: Taxes and
worth the
Cost of cutting taxes not
Elaine Power and Jamie Swift
savings
major political parties
in the
upcoming election are promising tax
especially as the post-holiday credit-card bills
arrive?
important questions we need to consider before jumping to
more
the conclusion that tax cuts are a good thing: a) will tax cuts really put
are the costs of those tax cuts?
what
and
b)
in
our
pockets?
money
two
income
The first problem is that tax cuts at the federal level mean, in part, reduced
to
download
the
municipalities.
problem
transfers to the provinces, which then
to the
We've already lived through a decade of decreased federal funding
services.
of
tax cuts and downloading
provinces, compounded by provincial
Raise taxes. ur
So Ontario's city governments must make tough decisions:
all of the above
Or
free.
once
were
services. Impose user fees for services that
a
new
version
people, especially
the
of the old "trickle-down" theory of economics. Some
more affluent, may end up with more money Decau
Ottawa's tax cuts. But it is not a sure thing.
More important are the costs of tax cuts.
What doesn't get
cant
funded-or is inadequately funded-because
healh
afford it'? Tax cuts affect programs that Canadians value: education
and
p p o r t programb, au
care, public health, the environment, income S
support
programs,
for all?
so
o
ssible to
wage? Evidence from the past 10 years of tax-cutting in Ottawa and Queen's
Park, combined with a retreat from social housing programs, suggests not.
Downloading onto municipal governments also underpins the neo-liberal
worldview. Our cities have the least fiscal capacity and are least able to regulate
a market dominated by a small number of ever more
powerful corporations.
Canadians are not overtaxed. The Organisation for Economic
Co-operation
and Development ranks Canada
among the lowest taxed industrialized nations:
21st among 30
industrialized nations, and fifth among the seven
largest.
I1, when Canadians saw themselves
after
World
War
as
nation-builders. In the wake of the events of the 1930s and 1940s, we had a
collective sense that no one should
ever
again have to suffer the humiliations of
unemployment and poverty experienced during the Great
Depression.
Canadians believed then-as we do
nowthat we could look after each
other and work
together to achieve whatever national goals we set for ourselves.
We could
build a better future for all
Canadians. We still can.
Xes are the price we pay for a decent, caring, and civilized
society.
acandidate promises
.
you tax cuts, ask him or her what the real cost
instead of gazing down at the bottom line, lets start asking ourselves
Kind of Canada we want to build
together. And ler's demand that Our
politicians work for the
Wewove our social safety net
Jamie Swift
produce for profit.
lax cuts already have a proven track record: The Walkerton wa
Source: Power,
E.,
Tton
ongoing crisis
in health-care
water disaster
in
in
ving
funding. Aboriginals living
Third
World
public good.
r teaches in Queen's School of
Physical and Health Education and
teaches in
Ihey erode "public goods" such as clean air and water that arc i
n
care
afordable housing for the alarming number of workers who do not earn a living
"Great" we think. Who wouldn't want more money in their pockets,
It's
evidence
-that the market can always
Evidence from the American experience suggests not. Can the market provide
cuts to "put more money in taxpayers' pockets."
are
ideological position, often called neo-liberalism,
better than government.
Toronto Star
There
particular
Drovide goods and services
health
But can the market provide
By
Two of the
a
which argues-withou support
Queeni's School of Business.
Toronto Star, A17. & Swift,
J. (2006, January
19). Cost of cutting taxes not
worth
the
savings.
Health Policy in
Cang
Anada
284
cD.
of the OECD,
the
the
Health
average public
developed
the 34
domestic
socia
estic product
(GI
Among
21.9 percent of gross
nations
in 2012/13
expenditure
was
There is great
variation
among
at
32.8 percent
until recently,
Canada ranks 26th of 34
social.
social
of GDP.
nations, spending
just 18.3 percent of GDP
on
highest
Canada compares
9.1 shows how
its citizenry as indicated
resources to
number ot OECD
spender
Mexico
6.6
Luxembouurg
Korea
Israel
Hungary
SlovakRepublic
0.9
Slovenia
spending just
spending on family benefits is 2.55
percent of GDP.
comprises tanuy
Income support to other age groups in the population
governments to help
lude
benefits, wage subsidies, and child support paid by
Social services in
of
out
families
poverty.
low-income individuals and
commun
8.
South Africa
in poverty. Canadas old-age
of GDP spent on old-age pensions
of
12.8
percent, with 4.5 percent
average
the lowest spenders on incapacity
(OECD, 2013b). Canada is also among
GDP Canada
than
less
percent of its
or disability-related issues, allocating
economies,
of
29
developed
28th
also ranks very low on family benefits, at
average tor
OECD
The
families.
on
GDP
1.43 percent of its
Consisten
0.6
with its spending on other social and health policy areas, Canada spe
7.5
7.7
Chile
chanrer
services.
7.5
Czech Republic
living
other
6.9
Poland
public
health spending. The US ranks
comes from private sources.
of GDP as more of its spending (52 percent)
and supports to citizens-that is, health
It is in the other areas of benefits
limited support compared to other
related policy-that Canada provides
Canada remain among the 10
economies. Old-age poverty rates in
developed
7.2
with
percent of seniors aged 65 and
lowest observed in OECD countries,
benefits rate falls below the OECD
counselling, employment supports, and
6.2
Russian Federation
Canada represents about 70 percent of toal
health care, spending 48 percent
low on
over
.I
.2
This
by the percentage of GDP allocated to
previous
5.9
Estonia
Turkey
nations in
countries. As noted in
Capital
3.9
India
old age benefits, incapacity-related benefits, and Gmilies.
expenditures health,
were at 10.2 percent of GDP in 201a
Canada's health expenditures
It ranked 22nd in haal
from 11.2 percent in 201l (OECD, 2013a).
down
Percentage of
China
on
expenditures among 34 wealthy
care in
public spending on health
as
I n d o n e s i a
19.8 percent o n social expenditures
the US which spent
is below
How do these differences in spending translate into specific policy areac)Figure
to a
Current
9% G D P
expendi
tures,
had been the
developed
industri
ial expenditures
public social.
Health
GDP 2011 (or nearest year)
1untries. Belgium, Denmat
of
leader in social spending
Public Expenditure on
Figure9.1a: Pu
countrie
GDP
ofcCDP
Perspective
285
a
on
more
(OECD, 2014a).
on
30 percent or
France all spent
o n social expenditures. I.
GDP
its
28.4 percent
Sweden spent
but France is the
so.
Finland, and
in Broader
Policy
services
percent of GDP on unemployment benefits and 1 percent on so
3.9
Brazil
Ireland
3.9
Australia2
5.9
9.0
Finland
9.0
Iceland
.1
Greece
Italy
.2
Norway
9.5
Spain.
OECD Average
9.3
United Kingdom
9.4
Sweden
Japan
9.5
2
9.6
10.2
Portugal
New Zealand
Belgium
10.3
10.5
10.8
Austria
Denmark
10.9
Swizerland
11.0
Canada
|11.2
Germany
France
Necherlands
United States
11.3
11.6
11.9
percent
below the OECD average of 2.4 percent (OECD, 2014a). It spenas
27th o
of GDP
on
income supports
and 2.2 percent
on
to
the working-age population ra
social services
(rank eighth of 30).
17.7
0
.Toral
8
pendirure only; 2. Data
reters
to
2010;
10
3. Data refers
12
to
2008.
14
16
18
20
Hcalth Policy in Canads
286
Health
Policy
in
Figure 9.1b: Public Expenditure on Old Age as Percentage of
Figure 9 . 1 c :
GDP, 2009
GDP, 2 0 1 1
Mexico
Mexico
Broader
287
Perspective
Public Expenditure
on
Incapacity as
Percentage of
0.1
Turkey
lccland
).5
| 2.1
Korea
Korea
Chile
.
Australia
0.8
Canada
3.6
Chile
Canada
New Zealand
4.)
Japan
7
United States
France
Israel
Iraly
Ireland
1.9
Slovak Republic
Netherlands
Portugal
Noorway
Germany
Denmark
Caech Republic
.
United Kingdom
Slovenia
Slovak Republic
Ireland
Luxembourg
Austria
OECD Average
Sweden
Czech Republic
Poland
7.9
United Kingdom
8.2
New Zealand
3.3
9.9
Switzerland
9.9
Spain
Slovenia
10.2
Belgium
lceland
10.9
Germany
1.5
Isracl
Poland
1.8
Netherlands
Portugal
12.3
France
ltaly
2.8
2.8
Norway
Greece
Austria
.0
6
Luxembourg
Belgium
Japan
.5
Australia
Spain
Hungary
Finland
2
Estonia
8
Estonia
| 2.2
OECD Average
.8
Turkey
| 2.1
Hungary
6.5
Swizerland
United States
5.9
Finland
Sweden
13.5
J./
.
.3
Denmark
.7
0.5
1.5
4.
Health Policy in Canada
288
Figure 9.1d:
Public
Expenditure
on
Family as Percentage of
in Broader
Health Policy
289
Perspective
Hurricane Katrina Reflects the Lack of Social
Box 9.5:
United States
Infrastructure in the
GDP, 2011
1.13
Mexico
been associated with race. Hurricane Katrina
Inequalities in the US have long
and
the lack of public supports for people who
exemplified racial inequalities
and were too poor to leave New Orleans before
owned
lost everything they
| 1.16
Korca
United States
1.31
1.37
|1.43
Chile
Greece
Canada
the storm hit.
and
Porruga
Spain
74
Japan
1 76
Poland
1.88
Swizerland
fund schools harms
not the only ones who are suffering. The uneven way we
white students as well as students of color. The way our institutions perpetuate
2.01
Italy
|2.13
Netherlands
and increase wealth disparities has shrunk the middle class. Slashing social
2.19
Slovenia
safery
2.32
2.43
srael
Slovak Republic
personal responsibility
has
new discourse on race and class that highlights how the public and private are
telated, how
2.71
Austria
of increasing
name
way we think and talk about race in this country, bur also for developing a
2.55
OECD Average
programs in the
we can use the Katrina crisis as a launching pad not only for investigating the
2.45
Estonia
net
added millions of people to the ranks of the working poor. Consequently,
2.44
Caech Republic
like canaries
just
"Racial disparities are leading indicators of trouble,
trouble
the marginalized are signaling that this democracy is in
for
air,
gasping
structural arrangements are
themselves
and
are
reproducing
because injustices
Withour a doubt, the greatest
benefiting a few at the expense of the many.
shouldered
are
by poor people of color, but they are
burdens in this country
|1.44
1.51
Australia
3.05
Germany
20
Norway
.22
aviding people, it can bring them closer together in a collective reimagining
of a
Finland
3.32
Belgium
3.36
New Zealand
just sociery" (p. 68).
ure
Powell, J.A., Kwame Jeffries, H., Newhart, D.W.,
OTative view of
3.55
Iceland
democracy and structrural arrangements that produce disparate
incompatible, and why institutional inequality concerns us all.
outcomes
n this way, our discussion about race can become transtormative; instead or
are
2.79
The crisis and
opportunity
&
Stiens, E. (2006).
1owards
of Katrina. In C. Hartman
&
a
uD
CEds.), There is no such thing as d natural disaster: Race, clas, and Hurricane Karrina (PP:
59-84). New York:
3.61
Rourledge.
3.64
France
race:
6)
Sweden
J.97
Luxembourg
4.00
Hungary
with support tor
employment
and other policies
workers who have training
Canada
their jobs through restructuring.
that
3.5
United Kinggdom
2.5
0.5
for Figures
20136
Development.
-operation
aiA
tor
promote
contributeu
Denmark
ource
Active labour
Dour policy is another area of government spending. cOnccti
. 0 5
Ireland
and
Economic
9.1a-d: Organisation for
mpenditure
darabase,
www.oecd.org/els/sociai
cP
r
e
.
h u p : / / b r . d
Just
dVe
cent
lost
of its GDP to
this
area
2015a).
in 2013 (OECD.
Health Policy in
290
Canad,
Health
Policy in
Broader
291
Perspective
of Net Replacement Rates over 60
Figure 9.2: Average Percentage
IMPLICATIONS FOR PUBLIC POLICY AND HEALTH
Months of
How do public policy commitments affect differing living conditions, which
are known to be key determinants of health? Some of the issues examined her
are resources available to the unemployed, the level of social assistance benchin
minimum wages, and pension benefits. These can mean the difference berue
Unemployment, 2011
Luxembourg
Slovenia
Israel
Denmark
having income, employment security,
having poor health.
and
good health, and living in Dowee
Necherlands
9
and
Switzerland
Iceland
Japan
Unemployment Benefits
Norway
Ireland
benefit replacement for individuals-at the
Figure 9.2 shows the percentage
over a five-year period for
worker
level-unemployed
average production
Most Canadians can
initial and long-term unemployment (OECD, 2014a).
about 50 weeks. After exhausting these
for
insurance
(E)
collect employment
need to spend them in order to be
benefits, a family with liquid assets would
Canada
benefits.
provides 73 percent replacement
eligible for social assistance
This is higher than the OECD
income during periods ofinitial unemployment.
coverage tor
Most nations provide lower replacement
average of 68.9 percent.
aboe
coverage, just
unemployment. Canada provides 49 percent
long-term
the OECD average of 48.9 percent.
Portugal
Caech Republic
Finland
Canada
71
Spain
Belgium
8
Austria
48.7
OECD Average
8.9
Poland
9
Germany
Italy
Hungary
Sweden
Social Assistance or Welfare
The OECD
resort
considers social assistance and welfare support
(OECD, 2014a, p. 114). On average,
more on
nost
as
countries
to
its oflas
benet spend
generally
services. Ostensibly,ne
on social and health
countries
reduce or avoid poverty. In a numberof
cash benefits than
social assistance is
benefir
levels fall well below the poverty line.
assistance
On the whole, countries with more general social
provide a housing benefit, which pushes the benefit closer to
alo
United Kingdom
Estonia
New Zealand
the medan
United States
vitzerkand
Australia
Korea
countries
Finland, Sweden, Iceland, and Luxembourg all provide a housing
Greece
Most o
generous social assistance benefits.
social democratic and conservative welfare states, wItn
Ceptionof
The supl
p p o n
reland and the United Kingdom, which are liberal welfare sti0 Deren
level provided is less than the relative
poverty
median income in international
comparisons.
level, measure*
59
benehts
Turkey
addition to more
62
Chile
bencfitin
income. Japan, Netherlands, Ireland, Denmark, United Kin
are
51
France
Slovak Republic
0
20
Ong- lerm
30
0
Unemployment Replacement Income
urteOrganisation
OECD social indicat for EconomicO-Operation
atS:
Co-operation
60
Initial
90
100
Unemployment Replacement Income
and
ana Development. (2014a). Sociery at a glance:
OECD. Retrieved from
www.occd.org/els/social/workincentives.
Health Policy in
Canada
292
Figure 9.3: Net Income Level Provided by Cash Minimum-Income
Benefit, Including Housing Assistance or Not, in Percentage of
Median Household Income
Health Policy
Cioure
in
Broader
9.3: Net Income Level Provided
Median
100
90
30
50
Household Income
20
0
10
Netherlands
United Kingdom
Switzerland
Finland
Sweden
lceland
Luxembourg
Czech Republe
Iceland
Luxembourg
CaechRepublic
Germany
Germany
Austria
Austria
Norway
Belgium
Norway
Belgium
France
New Zealand
France
New Zealand
Australia
Australia
OECD Aerng
OECD Average
Estonia
Estonia
Spain
Spain
Hungary
Hungary
Israel
Israel
Korea
Korea
Slovenia
S l o v e n i a
Poland
Poland
Porrugal
Canada
Portugal
Canada
S l o v a kR e p u b l i e
U n i t e dS i a u s
Slovak Republic
Unired States
Chile
Chile
Greece
Greece
ltaly
Turkey
laly
Turkey
0
40
30
20
20
10
i n c o m e
30
40
50
60
70
80
median
2011 without housing benefit
2011 with housing beneht ()
2007 with housing bgnefht
Restative poverty
Restative
of
level (5096
poverty level
inco
median
of
(609%
100
United Kingdom
Switzerland
Sweden
60
90
50
Denmark
Finland
70
70
Ireland
Denmark
B0
60
50
Netherlands
Ireland
0
40
30
20
Japan
Japan
100
(cont)
Part B. Couple with two children
30
40
by Cash Minimum-Income
in Percentage of
Renefit, Including Housing Assistance or Not,
Part A. Single Person
60
0
293
Perspective
E
OECD.
(2014b). Tax-beneft
-benefit
models. Retrieved
Retrieve
from
www
oecd
Aralalt
1/...
90
100
295
Health Policy in Canada
294
contrast,
In
non-European
means-tested
provide
of
1990). The aim
Andersen,
situation
of recipients,
but
to
and
and
beneits
generous
such benefits is
meet
to social
housing benefit provided
non-Anglo-Saxon
less
countries tend
to
benefits overall (Fni
n o t to
their immediate
sping-
address the
needs. In
g-term
Canada.
the
recipients is small. In 2011.an
25 percent of median income with a
assistance
received
in Canada
unattached individual
with two children received
A married couple
of 1.2 percent.
benefit
housing
benefit of 0.6 percent.
with a housing
median income
percent of
35
Minimum Wages
OECD countries
ninth
Canada ranked
wage among
2015b).
and in 2013 (OECD,
minimum
on
in 2007,
Figure 9.4
economic crisis,
on minimum
before the 2008
with other nations
Canada compares
that enables
that show how
level
data
a
at
provides
a r e provided
is that minimum wages
health and keep
The
maintain their
wages.
order to
require in
Healch
Policy in
Broader
Perspective
HqKaxuuni.ojo)
3oues.
ejuoAo|s
ppeiuesjeaz MaN
E?ni1od
eyeasny
KeBunH
unspg
puejod
concern
people
obtain what
to
they
line.
them above the poverty
(OECD,
wage
the
45 percent of
minimum
minimum wage is
full-time
Canada's
and o n e
children
with two
Canadian
A
family
income.
two-paren
household
2015b). A
of the median
full-time at minimun
e a r n e r is at 47 percent
wage
employed
and both parents
two children
is theretore identincu
tamily with
income. This family
of median
industrialized counte
receives 45 percent
wages
Oth for
developed
Of 15
and
low-wage-earning
median
family.
working
benefits for lone-parent
Canada ranks ninth for
families.
benefits for rwo-parent working
as
a
families
puerp
Kueuio9
spwouepjusuarqyi»Npnjun
!1qnd»y qeAoIS
peu
2ue
Pensions
The Canada Pension Plan
p r o g r a m p a i d to
(CPP) is
an
pro5 orking
plan during of nension
income benent
the
contributed to
retired individuals who have
data on the
OECD compares
lives (OECD, 2015b). The
the
gross carnin
nation in relation to
valu
benehts
provided by each
a
ensions
fearning
spends less than 5 percent 5I
perecer
CPP
provides
the
income,
median
worker earning
OECD
the lowest
levels are
orG
production worker. Canada
ror
avenige
Lanadas
replacement
among
of
natio
Snoquaxnj
urede
ueder
ejuos
soPas poyun
o 1xoN
oqndoy ypou
297
Health Policy in Canada
296
People with
Support for
expenditures
of GDP
less than 1 percent
remained
IMPLICATIONS
FOR
unchanged
disability benefits
toward
ranks 30th
among 34
since
DECD,
industrialized nations,
no
2003.
HEALTH POLICY
AND THE
CANADIAN WELFARE STATE
Canada's
approach
undeveloped
as
to
health-related
to other
compared
and
social democratic
conservative
Canada is
understandable when
public policy appears
industrialized
welfare
states.
recognized as a
to
be radher
nations, which include both
These
findings become
liberal welfare state, in
is
ideological inspiration
primary governmental
2003;
(Saint-Arnaud & Bernard,
one
which the
of minimizing government
Banting
&
Myles, 2013). The
health and health-related
and implementing
implications of this for developing
and societal barriers to
formidable
ideological
that there are
involve the
o v e r c o m e may
public policy are
be
can
which these barriers
care system in
such action. The m e a n s by
health
maintaining the public
intervention
same
processes
Canada:
discussed
in
building political
terms
of
and social
movements
health.
in support of
and
typology to health policy and
health
outcomes.
outcomes
ca
and o
the social democratic, Christian
their neaa
and
compared
North
America,
and
of
fascist
regimes
Europe
social spending patterns and the impact on
care,
by
tended
Anglo-Saxon regimes
rates
the lowest infant mortality
Social
been
have
area.
in this
& Shi, 2001). These findings
1960 to 1996 (Navarro
Coburn, 2006).
for the period
(Navarro e t al., 2004;
r e c e n t analyses
m
o
r
e
welfare s t a t e regimes
replicated in
o n health in
expenditures
shows public
Table 9.2
democratic regimes have
Christian
and 2010 (OECD, 2015c).
had the
berween 1985
Christian democratic regimes
democratic regimes.
o n health
Surpassed social
Navarro and Shis (2001) findings
from
difters
This
highest coverage. r e a s o n s for this difference are n o r clear. The ideological
The
expenditures.
choices. Consistent with
contrast, the liberal d e m o c r a t i c countries had
affect
commitments of governments
public policy
have the lowest health
findings, liberal welfare states
Navarro and Shi's (2001)
the United
economies,
the liberal Anglo-Saxon political
expenditures. Among
to the other
health
compared
expenditures
the
highest
States continues to have
consistent with Navarro and Shi's (2001) findings,
liberal welfare states. Also
infant mortality rates compared to
social democratic regimes have the lowest
(OECD,
2015a). Infant mortality is
Christian democratic and liberal regimes
health.
overall
of
indicator
a
population
good
a
Specifically, they exa
democratic/conservative,
health
on
public
regimes had the largest
regimes. In
lowest expenditures
to have the
democratic
the Christian
Political ideology and its manifestation in public policy is key influenceon
welfare state regime and
relationship between
in social democta
health tends to be better
summarized:
population
Succinctly
related the weuu
Navarro and Shi (2001)
worse in liberal nations.
nations
democratic
followed
health and social expenditures, health-related public policies, and ultimately
The
state
Perspective
POLITICAL IDEOLOGY AS AN INFLUENCE
HEALTH OUTCOMES
WELFARE STATES AND
health
Broader
social
1960 and 1990,
Berween
Disabilities
Canada allocates
Canada
means that
2015a). This
has
This allocation
Hcalth
Policy in
liberal,
four
population health status
) thelevels
main areas: (1) the primary determinants of income inequaliticS
suppor
of services for families; and (4) infant mortality as a measurc
adiions
public
of public expenditures and health care benefit coverage;
() Pnulation
a g e ; (3)
health status for the period 1946 to 1990. Theyfound that poe ad
committed to the redistribution of economic and social resou
m o c r a t i cparties
employment policies, such as those found in the social demo
status.
tended to be more successful in enhancing population healtn
population health outcomes. Esping-Andersen's (1990) typology is therefore
relevant to understanding how health policy is made and implemented in
Canada. Given that Canada has a
public health care insurance system, is it
for Canada to be
lumped in with the United States in the liberal
ppropriate
Custer?
Initially
and
US
it
would appear
public policies
on a
not,
but the similarities between Canadian
range of
health-related public policy approaches
Pear to support this placement (Bernard & Saint-Arnaud,
2004). This has
been
the case
PClaly
recently, as differences between the two countries may
have
narrowed as a resul
sult of closer
1980s and into
integration of their economies during the
the 1990
90s as a result of
free trade
de Agreement and the North
treaties,
ecifically the
Free Trade
plte of trade agreements American
Agreement.
the two
linking
rivate
political economies, the
still has
health care system for
apublic
system
to
most of the
population,
which all citizens have
access
Free
d
while Canada
on
the basis
or
Health Policy in Canada
298
Public Expenditures
Table 9.2: OECD
on
H e a l t h
Policy in
Broader
need, n o t i n c o m c .
Health, 1985 to 20100
Perspective
Although about 30 percent ofhealthtarc ants in (anara
not covered by the public system- very high figure in internatinnal
mparison-and there is increasing privatization of parts of the anadian
Leelch care system, Canada still scores higher than the US in terms of accen for
are
1990
1985
Social
democratic
political
Denmark
Norway
Finland
Mean
France
8.1
5.5
7.7
8.3
8.9
6.7
7.2
6.7
7.7
8.2
6.9
7.4
7.5
8.1
8.5
9.6
10.1
Mean
Latin (former
10.2
10.8
7.6
9.3
10.3
10.5
7.4
8.8
9.8
10.5
7.4
8.6
7.6
5.1
6.3
6.1
6.5
7.6
9.5
11.3
12.5
8.4
8.3
7.8
8.7
Spain
Mean
5
3.0
14.6
9.1
9.8
7.8
6.8
6.1
Source:
OECD. (2015c).
(database).
Health Staristics
and
care services they need
And while social inequalities, including income inequalities, have been
growing in Canada, it continues to emerge as more egalitarian compared to
the United States in terms of redistributive health and social policies (Siddiqi
11.0
8.9
9.8
9.1
9.3
uure indicatos U
2007; Broadbent Institute, 2014). Figure 9.5 shows the Gini
coefhcient for OECD member countries in 2010. The Gini coeficient measures
tie
distribution of income and varies between 0 and 1. A Gini coeficient of
means there is
no income
inequality. A value of 1 means one person owns
wealth. Canada's Gini coefficient is .32,
compared to the United States
t.8. These values are much higher than those of social democratic and
al the
ristian democratic regimes, which all have Gini coefficients less than the
OECD average of
.31
Whether these specific differences between the Canadian and US
aith care systems and health-related public policies will maintain
aiterent
profiles remains uncertain. Since these hgures came out
Canada
has
negotiated free trade greements with the European Union (in
ember 2014) and other countries
(Global Affairs Canada, 2015). It is
that finalizing the
ated
ake
agreement with the European Union may
few
a
new
c
0.1787/data-00349-en.
more years. Most
such agreements tend to promise "opening
and job
It is unclear
creation
what impact this agreement
W
Tree trade
environme
will
markets
and oth
the
inancing
http:/ldx.doi.org/1
DOI:
16.4
10.6
8.7
7.5
5.2
expendirure
9.4
8.3
5.5
Healtn
Health
8.4
7.6
7
5.4
8.5
8
7.2
6
Greece
shift to economic globalization and the intense marketization that has
in
Occurred in some service sectors Canada.
And while low-income populations in both Canada and the US are more
than high-income populations, a greater
ikely to report poor or fair health
Americans (31 percent) do so cornpared to luwlow-income
of
percentage
income Canadians (23 percent). In addition, the primary reasons for unmet
health care needs differ between nations. In Canada, wait times for carc have
become the most frequently given reason, whereas in the United States, it is
cost or lack of health insurance that deters Americans from sceking the health
&Hertzman,
economies
fascist dictatorships)
Portugal
11
10.4
7
7.1
Italy
9.8
9.5
7.6
Canada
9.9
10.3
8
Kingdom
United States
7.1
8
7.1
5.1
Australia
9.2
6.7
political
Liberal Anglo-Saxon
United
political
9.5
7.5
law-income populations (Sanmartin & Ng, 2004). Neoliberalisn, political
discussed in previous chapters, has contributed
idcology of the market
rhis
economies
7.7
8
Switzerland
Mean
8.5
8
8.5
Netherlands
8.3
7.1
6.9
Germany
7.4
8
6
Belgium
2010
a
7.3
(conservative)
Christian democratic
Austria
2005
economies
7.4
Sweden
2000
agreements
have
on
the Canadian economy%
imOr the health of the population. Chapter 11 considers the
potential pact ofagreemens
the
Pacihic Partnership
Comprehensive Economic and Trade and Trans
nts.
Health
Poliy
in
Cana
oader
Poliyin
Perspective
301
Pkcalch
WELFARE
STATE IN DECLINE
THE
rI noted how Canada and other\Western. developed political economies
health
social spending
response to global economic
Chap
roduced
and
in
has been done. it is stated. to enhance national competitiveness
oresures. This has
have roduced
in che
global economy.
zatve
orter
effects
Studies indicate tha less
health.
on
as
developed welfare states have
illustrated by higher infant mortality
rates
and
et al.. 2004). In other words. the more
lite expectancies Navarro
economic
resource redistribution. the berter
and
social
invest in
tend to be. In addition. iberal-which are
outcomes
health
oemmens
uation
ls Anglo-Saxon-economies
eder
appear
to
be
more
efects of neoliberalism and globalizarion
iuencing
& brles. 2013).
to the policy(Hemrijck. 2002: Banting
susceptible
Myles (2013) argue that Canada's economy
trade (p. 12), and is more open compared
iepends heavily
neoliberalism penetrated the Anglo-Saxon
has
countries.
Why
D other OECD
Banting
on
beral economies
gimes Why
and
international
to a
greater
are some
degree than in social democratic or conservative
welfare
such
purps
pues
Where insiurions of collective interest representation-social corporatism
institutions-are strong, where authoriy is
and inclusive electoral
concentrated, and where the welfare stare is based on the principle ot
universalism,
the effects of international
capital mobility are absent, or they
posiive in the sense that they sugeest economic and
politial interestS
oPpOsed to neoliberal reforms.... [In these countries, these
interests have
been successful in
defending the welfare state. (Swank, 1998, p. 44)
6uospnanqs uszr|
qeMjS
21qmday qpar
qeAws1uo»Ncj
pur
globalization-resistant resiliency.
He thus concdudes:
2re
eisny
pxuqenuday
resilient than others?
explanations have
in the age of erpansion now shape domestic responses to internationalization.
pspueuyenutsp
LSsucehuusnsar
npa
states more
been posited to account for
Swank (1992, 1998) argues that the
same class and political institutions that mediared and shaped the welfare state
As with other issues, many
incontrast, where political institutions fragment
representation and poa
authoriry, in the
as
E
yand
Anglo-Saxon democracies, the
of investment
ability
capital
place to place exerts downward
on social
pressure
provision.
a related explanation is to
TOm
and
consider the political
organization
specifically the electoral process. In Fighting
in the
to
or
turope, Alesina and Glaeser
Povery
(2004) address this very issue with regard
in the size
thar
of the welfare
s
state. While
1at
with Swank
institutions and political ideology
they agree
are
important infuences, they add
Health Policy
in
Canada
Health Policy in Broader Perspective
303
302
that the European
of grievances
socialist and
of the 19th
wars
among
the working
seats
not
is determined
receives in
political
a
variety
o
many European ations
representation, in which the percenr.
movements,
In response
of proportional
some form
instituted
of legislative
fuelled
provided fertile grounde
build support.
parties to
these organized
communist
to
and 20th centuries
classes that
an
on
the basis of the
election. This
means
percentage of votes
entage
tha.
smaller-and tusual
policymaking to a much
that
party
in
can gain inffuence
dominant-political parties
systems, which
in
hrst-past-the-post
case
the
is
extent than
are
L
he Canadian response
aamic
econon
to
the
economic pressure associated
with
increasing
globalization has further weakened the Canadian welfare state.
Much of this has
to
do with Canada
already being liberal welfare state. In
proportional representation makes it more difficult for
G-leaning political parties, such as the NDP and the Green Party, to infuence
blic policy. The liberal political economies appear to be more susceptible to
to the
.dition, the
a
absence of
nliberal-influenced
demands of economic
responses
isue further addressed in the next chapter.
globalization,
an
typical nf
greater
Lett or socíal democratic parties have been able to
liberal political economies.
their goals of more comprehensive welfare states,
further
to
use this mechanism
representation is an excellent predictor
of
proportional
such that the presence
welfare states.
of the size and depth of
but has had periods
Canada does not have proportional representation,
left party (the Co-operative
the
when
of minority federal governments,
the NDP) have held the balance of
Commonwealth Foundation and later
times,
these
especially during the 1960s, that progresive
power. It was during
wee
and Canadas health care system
as public pensions
such
changes
establishment of proportional representation
the
established. In Canada,
and the
like the New Democratic Party
would enable smaller political parties
and
on the political system
infuence
more
and
Green Pary to gain m o r e seats
rase
representation
The arguments for proportional
public policy o u t c o m e s .
area rich for further
state. This is an
with respect to the welfare
issues
ot
interesting
development
the
the welfare state and
research into its value in furthering
health
care
and health-related
public policy.
s
of the weltareliberal
and function
examined the form
This chapter has
Esping-Andersens
Canada fits into
examined how and why
the Canad
t
has
group. Being
health and social
a
proach
to
shaped
liberal welfare s t a t e
has implicat
approach
this
and
programs,
developed weltare s t t h
health
More
and well-being.
population health
and better popula
and social expenditures
health
increased public
investment
have the highest
while
regimes
best population
social spending and the
Social democratic
states
have the lowest
pCnding
in these
arcas
spending
and
has declincd
health
o u t c o m e s .
the
lib
O u t c o m e s ,
worse
since
What was your reaction upon hnding out that Canada is considered a
liberal welfare state?
2. How do business interests dictate health policy in Canada?
3. Should the Canadian approach to provisions of citizen benefits and
supports be reoriented to be more like those seen in European nations?
What would be the arguments in favour of this? What
could be
1.
arguments
used to oppose this shift?
What
public policies would
need
to
be
changed to improve the economic
security of Canadians, thereby improving their health and qualiry of life?
What
are some
of the barriers
to
having Canadians
become
aware
of the
importance of public policies addressing economic and social security
determinants of health and quality of life?
as
FURTHER READINGSS
cONCLUSiONS
welfare state
CRITICAL THINKING QUESTIONS
1980s.
In addition
Alrcady at
a
a
he
Canadas
v
a
n
t
a
g
e
amDra, C. (2007). Going beyond the three worlds of welfare
capitalism:
gime theory and public health research. Journal
of Epidemiology a14
Community Health, 61(12), 1098-1102.
of this analysis, Bambra reviews the
original
states and
dre
provides the range of related Esping-Andersen ypo10
cse find
MOst
Canada to
be
a
conceptualizations.
firm ex
exemplar of a liberal welfare state.
o
ting. K., &t Myles, J. (Eds.).
(2013). equality andshefading ofredistributive
5. Vancouver and
Toronto: UBC Press.
This volume
welfare state and contains contributions on various aspects of the changing
changing approaches
appr
to social provision in Canada. The