Institute of Intergovernmental Relations

Institute of INTERGOVERNMENTAL RELATIONS
Institute of INTERGOVERNMENTAL RELATIONS

Why it is so hard to reform health-care policy in Canada:

Lessons from a Cross-Provincial Comparison of Health- Care Policy Reform in Canada

Latest update: January 23, 2014

This research project was launched in the early 2000s. It is based on the findings from 30 case studies that were selected as representative of health-care policy writ-large. A common methodology was used in assessing the 30 cases.

The cases describe and assess the nature and extent of health-care policy reform in Canada between 1990 and 2003 and set out the factors that account for the limited reform. The findings are updated to cover the 2004-2011 period.

This note provides the status of the research, lists the members of the research team, and acknowledges the sources of funding.

Research Status and Publications

Expand this box to see the project outputs listed under four headings: main findings, 30 case studies, background studies and other papers and presentations.

Main Findings

The project entailed an assessment of the nature and extent of health-care policy reform in Canada since the beginning of the 1990s, sets out factors that account for the meagre reform that has occurred since then, and analyzes the prospects for reform going forward. The volume is based on studies of a representative series of policy-reform issues drawn from four policy categories: governance arrangements, financial arrangements, delivery arrangements, and policy content. From these categories six issues were selected: regionalization, needs-based funding, alternative payment plans for primary care physicians, for-profit delivery, waiting lists, and prescription drug coverage.  Each of these six issues was studied in five provinces: Alberta, Saskatchewan, Ontario, Quebec, and Newfoundland and Labrador. Data were collected using key-informant interviews, supplemented by a review of publicly available documents about these policies.

Each of the 30 case studies involves: description of the context within which the case was studied; the nature and extent of reform; and analysis of the factors that influenced policy-making processes at the various stages of the decision process (to the extent that there was reform). It thus focuses on whether and why an issue became an agenda item that required government decision; and for those cases in which a reform decision was taken, the factors that shaped the policy choice.  The case studies focus initially on the 1990-2003 period (primarily a period centre and left-of-centre provincial and federal governments) and the analysis is extended to the 2004-2011 period (primarily a period of centre and right-of-centre governments).

Each of the cases is analyzed in relation to a specified definition of reform. These definitions are based on the consensus about the desired nature and extent of reform as set out in the reports of the many provincially and federally appointed commissions, task forces and advisory groups beginning in the second half of the 1980s. The data are then analyzed from cross-issue, cross-provincial, and cross-ideology perspectives.

The main findings are set out in Paradigm Freeze: Why It Is So Hard to Reform Health Care Policy in Canada. It is published by McGill-Queen's University Press for the Institute of Intergovernmental Relations in the Queen's Policy Study Series, School of Public Studies.

Copies can be ordered from McGill-Queen's University Press

30 Case Studies

All case study authors used the same methodology for consistency. The 'inputs' from their case studies were used for intra-provincial analysis as reflected in chapters 3-7 and also for cross-province and cross-issue in chapters 8-11 of Paradigm Freeze: Why It Is So Hard to Reform Health Care Policy in Canada.

The case studies are available for download below this paragraph. Each author had the freedom to organize his or her findings in whatever style he or she preferred. Thus, these papers vary in presentation and style but share common objectives and analytic frameworks. Some of the 30 cases have been published in peer-reviews journals, while others remain unpublished. Links to published works are provided; for those papers labelled "unpublished," they may not be cited, reproduced, or distributed without permission of the lead author

Alberta Case Studies

Church, John and Neale Smith. 2006. "Health Reform and Privatization in Alberta." Canadian Public Administration, Vol. 49, No. 4 (Winter): 486-505. Abstract available at http://www3.interscience.wiley.com/journal/119819740/abstract.

Church, John and Neale Smith. 2008. "Health Reform in Alberta: The Introduction of Health Regions." Canadian Public Administration, Vol. 51, No. 2 (June): 217-238. Abstract available at http://www3.interscience.wiley.com/journal/120695818/abstract.

Church, John and Neale Smith. 2008. "Shifting the Lens:  The Introduction of Population-Based Funding in Alberta." Healthcare Management FORUM, 21(2) (September): 36-42. Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18795557.

Church, John and Neale Smith. 2009. "Health Reform and Wait Times Policy in Alberta under the Klein Government." Canadian Political Science Review, Vol.3, No.4 (December): 63-84.

Church, John and Neale Smith. 2013. "Health Reform and Drug Policy in Alberta." Unpublished.

Church, John and Neale Smith. 2013. "The Introduction of APPs in Alberta." Unpublished.

Saskatchewan Case Studies

McIntosh, Tom and Michael Ducie. 2009. "Private Health Facilities in Saskatchewan: Marginalization through Legalization." Canadian Political Science Review, Vol.3, No.4 (December): 47-62.

McIntosh, Tom, Michael Ducie, Marcy Burka-Charles, John Church, John Lavis, Marie-Pascal Pomey, Neale Smith, and Stephen Tomblin. 2010. "Population Health and Health System Reform: Needs-Based Funding for Health Services in Five Provinces." Canadian Political Science Review, Vol.4, No.1 (March): 42-61.

McIntosh, Tom, Michael Ducie and Courtney England. "Comparative Provincial Health Reform Regionalization in Saskatchewan." 2007.  Unpublished.

McIntosh, Tom, Michael Ducie and Courtney England. "Alternative Payment Plans in Saskatchewan." 2007.  Unpublished.

McIntosh, Tom, Michael Ducie and Courtney England. "Coping with Fiscal Crisis: Drug Plan Retrenchment in Saskatchewan." 2007. Unpublished.

McIntosh, Tom, Michael Ducie and Courtney England. "Managing Wait Times in Saskatchewan." 2007.  Unpublished, available for download .  

Ontario Case Studies

Tables available for download.

The tables in this document are cited in the following chapter:

Lavis JN, Pasic D, Wilson MG. Health-care reform in Ontario: More tortoise than hare? Chapter 5 in Lazar H, Lavis JN, Forest P-G, Church J (2013). Paradigm Freeze: Why It Is So Hard to Reform Health-Care Policy in Canada? Montreal and Kingston, Canada: McGill-Queen's University Press; 2013, p. 89-111.

The tables are made available here for those who want additional details about each of the cases described in the aforementioned chapter. They are the tabular equivalent of the case-specific reports prepared for provinces other than Ontario. The tables can be cited as follows:

Lavis JN, Pasic D, Wilson MG. Health-care reform in Ontario: More tortoise than hare? - Online tables for chapter 5 in Lazar H, Lavis JN, Forest P-G, Church J (2013). Paradigm Freeze: Why It Is So Hard to Reform Health-Care Policy in Canada? Hamilton, Canada: McMaster University Program in Policy Decision-making; 2013.

Quebec Case Studies

Pomey, Marie-Pascale,  Martin, Elisabeth  and P-G Forest. "Budget allocation reform in Quebec: Using a population-based approach to allocate resources for medical and social services (except physical health)." 2006. Unpublished.

Martin, Elisabeth, M-P Pompey and P-G Forest. "The Reform of Front-line Services in Quebec: The Implementation of Family Medicine Groups (FMGs) and New Terms of Remuneration for General Practitioners." Unpublished.

Martin, Elisabeth, M-P Pompey and P-G Forest. "The Reform of Regionalization in Quebec: The Introduction of Bill 25 Proposing the Transformation of Regional Boards Into Health and Social Services Agencies and the Implementation of Local Service Networks." Unpublished.

Pomey, Marie-Pascale,  Martin,  Elisabeth and P-G Forest. "Indecision Making: The Privatization of Health Care in Quebec." Unpublished.

Pomey, Marie-Pascale,  Martin,    Elisabeth  and P-G Forest. "Making Decisions about Prescriptions in Quebec: Implementing the Public Prescription Drug Insurance Regime in 1996-1997." 2005. Unpublished.

Pomey, Marie-Pascale,  Martin,    Elisabeth  and P-G Forest. "Waiting List Management in Quebec:Implementing a System to Manage Access to Care." 2005. Unpublished.

Newfoundland and Labrador Case Studies

Tomblin, Stephen and Jeff Braun-Jackson. "For-Profit Provision of Medical Services:  The Case of Newfoundland and Labrador." 2005. Unpublished.

Tomblin, Stephen and Jeff Braun-Jackson. "The Doctor Is Not Available to See You Now: Alternate Physician Payment Models and Primary Health Care Reform in Newfoundland and Labrador." 2005. Unpublished.

Tomblin, Stephen and Jeff Braun-Jackson. "Wait List Management and Reform in Newfoundland and Labrador: What is the Prognosis?." 2005. Unpublished.

Tomblin,  Stephen and Jeff Braun-Jackson.  "Regionalization - Newfoundland and Labrador." 2005. Unpublished.

Tomblin,  Stephen and Jeff Braun-Jackson.  "Prescription Drug Reform in Newfoundland and Labrador: Reform or Lack of Reform?" 2005. Unpublished.

Tomblin,  Stephen and Jeff Braun-Jackson.  "Health Budgeting and the Experience of Newfoundland and Labrador: Why Haven't we Moved to a Needs-based System." 2005. Unpublished.

Other Papers/Presentations

The following are some of the published outputs and presentations of team members arising from the project research:

Church, John and Neal Smith. 2006. "Health Reform and Regionalization in Alberta." 2006 Canadian Association for Health Services and Policy Research (CAHSPR) Conference. 17-19 September 2006: Vancouver, Canada. 

Lazar, Harvey. 2009. "Health Care Reform Opportunities and Barriers: New Evidence from a Recent Period." Northern and Rural Health Conference, Ontario Hospital Association. 21 May 2009: Toronto, Canada.

Lazar, Harvey. 2009. "A Cross-Provincial Comparison of Health Care Reform in Canada: Building Blocks and Some Preliminary Results." Canadian Political Science Review, Vol.3, No.4 (December): 1-14.

Martin, Elisabeth, M-P Pompey and P-G Forest. 2010. "One step forward, One step back: Quebec's 2003-04 health and social services regionalization." Canadian Public Administration. December 2010. Volume 53, No.4.

Martin, Elisabeth, et al. 2006. "Elaboration and Implementation of Family Medicine Groups (FMGs): A Relevant Model for Primary Care Renewal in Quebec (Canada)?" 5th Nordic Health Promotion Research Conference. 15-17 June 2006: Esbjerg, Denmark.

Martin, Elisabeth, et al. "Elaboration and Implementation of Family Medicine Groups(FMGs): An Opportunity for Primary Care Renewal in Quebec?"

Martin, Elisabeth, et al. 2006. "The Reform to Regionalization in Quebec: Towards a New Model of Local Governance in Health Care." National Healthcare Leadership Conference. 12-13 June 2006: Victoria, Canada.

McIntosh, Tom and G. Marchildon. 2009. "The Fyke in the Road: Health Reform in Saskatchewan from Romanow to Calvert and Beyond. Forthcoming " In Saskatchewan Politics: Crowding the Centre, ed. H. Leeson. Regina: Canadian Plains Research Centre. 337-353.

Neville, Doreen, Gwynedd Barrowman, Brenda Fitzgerald and Stephen Tomblin. 2005. "Regionalization of Health Services in Newfoundland and Labrador: Perceptions of the Planning, Implementation and Consequences of Regional Governance." Journal of Health Services Research & Policy, Vol. 10, Supp. 2: 12-21. Abstract available at http://jhsrp.rsmjournals.com/cgi/content/abstract/10/suppl_2/12.

Pomey, Marie-Pascale, et al. 2007. "Le Régime Général d'Assurance Médicaments au Québec: Un Partenariat Public/Privé Confronté à des défis." Journal d'Economie Médicale, Vol. 25, No. 5-6 (Septembre - Novembre): 1-17.

Pomey, Marie Pascale, et al. 2007. "Public/Private Partnerships for Prescription Drug Coverage: Policy Formulation and Outcomes in Quebec's Universal Drug Insurance Program, with Comparisons to the Medicare Prescription Drug Program in the United States.The Milbank Quarterly, Vol. 85, No. 3: 469-498.

Pomey, Marie Pascale, et al. 2009. "Quebec's Family Medicine Groups: Innovation and Compromise in the Reform of Front-Line Care." Canadian Political Science Review, Vol.3, No.4 (December): 31-46.

Smith, Neale and John Church. 2006. "Health Reform and Wait Times in Alberta." 2006 Canadian Association for Health Services and Policy Research (CAHSPR) Conference. 17-19 September 2006: Vancouver, Canada.

Tomblin, Stephen. 2007. "Effecting Change and Transformation through Regionalization: Theory versus Practice." Canadian Public Administration, Vol. 50, No. 1 (Spring): 1-20. Abstract available at http://www3.interscience.wiley.com/journal/119818761/abstract.

Tomblin, Stephen and Jeff Braun Jackson. 2009. "Renewing Health Governance: A Case-Study of Newfoundland and Labrador." Canadian Political Science Review, Vol.3, No.4 (December): 15-30.

Project Team

For a list of the project team members, click to expand the box

Project Leader/Coordinator

  • Harvey Lazar, University of Victoria and Queen's Institute of Intergovernmental Relations, Principal Investigator

Associate Coordinators

  • John Lavis, McMaster University
  • Pierre-Gerlier Forest, Johns Hopkins University

Provincial Coordinators / Principal Provincial Chapter Authors

Issue Coordinators

  • Regionalization - Stephen Tomblin , Memorial University
  • Needs-Based Funding - Tom McIntosh , University of Regina
  • Payment Plans - John Church , University of Alberta
  • For-Profit Delivery - Alina Gildiner, Ministry of Health and Long-Term Care, Ontario (formerly McMaster University)
  • Waiting Lists - Claudia Sanmartin , Statistics Canada
  • Drug Plan Coverage - Marie-Pascale Pomey , Université de Montréal

Literature Review

  • Vandna Bhatia 2003. Theoretical Literature Review, Carleton University
  • Kevin O'Fee, Review of Grey literature, Saskatchewan Institute of Public Policy, University of Regina

Administrative Officer

  • Mary Kennedy, Queen's Institute of Intergovernmental Relations

Website Coordinator

  • Ryan Zade, Queen's Institute of Intergovernmental Relations

Research Assistants

Queen's University

  • Aaron Holdway 2002-2004
  • Ryan Zade 2006-2008, 2012-2013

University of Victoria

  • Julia Diamond 2011-2012
  • Bryan Gulka-Tiecheko 2011-2012
  • John Schmid 2010-2011
  • Jessica Hartog 2010-2011

McGill University

  • Daniel Wolfe 2011

University of Alberta

  • Neale Smith 2003-2006
  • Deborah Lafleur 2003-2006

University of Regina

  • Michael Ducie

McMaster University

  • Dianna Pasic 2003-2006

Université de Montréal

Memorial University

  • Jeff Braun-Jackson 

Editorial Services

  • Ellie Barton
  • Val Jarus
  • William Church, Q.C.

Project Funding

The team gratefully acknowledges the research funding provided by:

The views expressed herein are those of the authors and do not necessarily represent the views of the funders.

(Last modified: 2014-01-23)