Healthcare is top-of-mind for the great majority of Canadians. They worry about its sustainability and long wait times to access many services. Too many with lower incomes worry about paying for its uninsured prescription drugs, rehabilitation, home care, dentistry, etc. Together with social services, healthcare employed over 2.3 million people in 2016; it consumed some $228 billions of taxpayers’ (70%) and consumers’ (30%) money, some 11% of the Gross Domestic Product. By any measure, Canadian healthcare is a big and important business. Surprisingly, it lacks a governance. It has no single body to lead what we call the “system”, a governance that can be held accountable for how well or poorly healthcare is meeting people’s needs. It is inconceivable that other big businesses in Canada, the banks for example, would carry on without governing Boards.
Why doesn’t the healthcare “system” have a governance?
In the first place, it is a very fragmented enterprise. It is sub-divided into 14 related but separate ‘systems’, one for each province and territory and one to meet the particular responsibilities of the federal government. Although healthcare services – primary care, care by specialists, hospital care, nursing, rehabilitation, home and community care, etc. – are generally thought to be under the control of a provincial or territorial government, in fact the role of governments is more that of paymaster than governor. How this should be so is a complicated story, the core of which leads back to the 1962 doctors’ strike in Saskatchewan, the settlement of which laid the policy foundation of public payment for private practice. Ever since, although it varies province by province, most healthcare services have been provided by individuals who are self-employed and institutions and organizations that are answerable to their separate Boards of Governors. Provincial and territorial governments are responsible for governance of the publicly funded health insurance plans we Canadians refer to as Medicare. Governance of the ‘delivery system’ is widely distributed among the boards of hospitals, long-term care homes, mental health agencies, home care providers, etc., and the innumerable physicians, dentists, physiotherapists, and other private health professionals who own and operate their own or share in the ownership of team practices. At root, each of these service providers marches to the beat of its own drum! It is surprising that the elements of all Canada’s so-called ‘systems’ of health and healthcare services are as inter-connected and as coordinated as they are.
What’s to be done?
It is not realistic to think we could have a single pan-Canadian healthcare system; one for each provincial, territorial, and federal government is the practical starting point. Nor is it realistic to take governments out of the governance equation; they are the dominant paymasters for many elements – doctors, hospitals and a variety of other institutions and organizations. They must account to their taxpaying electors for how well or poorly public resources are spent. But with respect to governance, the policy direction of health and healthcare services, the majority of provincial governments are ill-suited for the role. Most encompass multiple regions and communities with many and diverse service needs and priorities that demand different, often conflicting approaches that are inconsistent with the broad jurisdiction-wide goals that politically-minded governments must, in the end, promote. Many if not most regional priorities will be of a nature that may not match those of governments focused on more immediate or province-wide imperatives. Governance of such systems requires priorities to be adjusted to focus on regional goals and objectives often well beyond a political time horizon.
This, together with the sheer size and marked diversity of the populations of Canada’s provinces and territories, argues for the establishment of regional healthcare system governances, funded by governments and answerable to them for system-wide goals but clearly and firmly at arms-length from them. Arguably the principle behind this approach has been adopted in Regional Health Authorities – RHAs – (and in Ontario’s Local Health Integration Networks – LHINs) but nowhere have these bodies been given the power, authority, and the funding necessary to actually govern the regional delivery systems on which Canadians depend. They should be so empowered and be held accountable two ways, ‘upstairs’ to the governments from whom their power and funding are derived and ‘downstairs’ to the people of the regions served by the healthcare sub-system they govern.
Relieved of the front-line governance and management issues of the regional sub-systems, the provincial and territorial governments could turn their attention to demanding policy issues such as how to blend healthcare services with the social determinants of health, creating a unifying vision and mission for each provincial/territorial system, and determining the permissible degree of regional variation allowable within the limits of service to the overall goals of the system as a whole. The regional sub-governances could then compete with one another in deploying their resources effectively to meet the needs of their populations, contribute to the mission in common, and approach realization within their regions of the provincial/territorial unifying vision and mission.
Authored by members of the Queen’s Health Policy Council: