Why is it so hard to reform health-care policy in Canada? 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.
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.
The views expressed herein are those of the authors and do not necessarily represent the views of the funders.
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.
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
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. DOI: 10.1111/j.1754-7121.2006.tb01995.x
- 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. DOI: 10.1111/j.1754-7121.2008.00016.x
- 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. DOI: 10.1016/s0840-4704(10)60544-3
- Church, John and Neale Smith. 2009. "Health Reform and Wait Times Policy in Alberta under the Klein Government." [PDF 420 KB] Canadian Political Science Review, Vol.3, No.4 (December): 63-84.
- Church, John and Neale Smith. 2013. "Health Reform and Drug Policy in Alberta." [PDF 192 KB] Unpublished.
- Church, John and Neale Smith. 2013. "The Introduction of APPs in Alberta." [PDF 335 KB] Unpublished.
Saskatchewan Case Studies
- McIntosh, Tom and Michael Ducie. 2009. "Private Health Facilities in Saskatchewan: Marginalization through Legalization." [PDF 223 KB] 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. [PDF 285 KB] 2007. Unpublished.
- McIntosh, Tom, Michael Ducie and Courtney England. "Alternative Payment Plans in Saskatchewan." [PDF 182 KB]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." [PDF 306 KB] 2007. Unpublished, available for download .
Ontario Case Studies
Tables available for download [PDF 331 KB].
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)." [PDF 675 KB] 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." [PDF 1.1 MB] 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." [PDF 930 KB]Unpublished.
- Pomey, Marie-Pascale, Martin, Elisabeth and P-G Forest. "Indecision Making: The Privatization of Health Care in Quebec." [PDF 0 KB] 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." [PDF 602 KB] 2005. Unpublished.
- Pomey, Marie-Pascale, Martin, Elisabeth and P-G Forest. "Waiting List Management in Quebec:Implementing a System to Manage Access to Care." [PDF 375 KB] 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." [PDF 564 KB] 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." [PDF 239 KB] 2005. Unpublished.
- Tomblin, Stephen and Jeff Braun-Jackson. "Wait List Management and Reform in Newfoundland and Labrador: What is the Prognosis?." [PDF 664 KB] 2005. Unpublished.
- Tomblin, Stephen and Jeff Braun-Jackson. "Regionalization - Newfoundland and Labrador." [PDF 576 KB] 2005. Unpublished.
- Tomblin, Stephen and Jeff Braun-Jackson. "Prescription Drug Reform in Newfoundland and Labrador: Reform or Lack of Reform?" [PDF 696 KB] 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." [PDF 350 KB] 2005. Unpublished.
- Bhatia, Vandna. "A Cross-Provincial Study of Health Care Reform in Canada - Academic Literature Review: Synthesis Paper." [PDF 715 KB] 2002. Unpublished.
- Bhatia, Vandna. "A Cross-Provincial Study of Health Care Reform in Canada - Academic Literature Review: Report Summaries." [PDF 586 KB] 2002. Unpublished.
- O'Fee, Kevin. "A Cross-Provincial Study of Health Care Reform in Canada - Academic Literature Review: Synthesis Paper." [PDF 469 KB] 2002. Unpublished.
- O'Fee, Kevin."A Cross-Provincial Study of Health Care Reform in Canada - Academic Literature Review: Report Summaries." [PDF 925 KB] 2002. Unpublished.
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." [PDF 7 KB] 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." [PDF 200KB] 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." [PDF 243 KB] 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)?" [PDF 183KB] 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?" [PDF 446KB]
- Martin, Elisabeth, et al. 2006. "The Reform to Regionalization in Quebec: Towards a New Model of Local Governance in Health Care." [PDF 183KB] 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. DOI 10.1258/135581905774424528.
- Pomey, Marie-Pascale, et al. 2007. "Le Régime Général d'Assurance Médicaments au Québec: Un Partenariat Public/Privé Confronté à des défis." [PDF 261 KB] 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." [PDF 515 KB] 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." [PDF 235 KB] Canadian Political Science Review, Vol.3, No.4 (December): 31-46.
- Smith, Neale and John Church. 2006. "Health Reform and Wait Times in Alberta." [7.8 KB] 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. DOI: 10.1111/j.1754-7121.2007.tb02000.x
- Tomblin, Stephen and Jeff Braun Jackson. 2009. "Renewing Health Governance: A Case-Study of Newfoundland and Labrador." [PDF 218 KB] Canadian Political Science Review, Vol.3, No.4 (December): 15-30.
Project Team
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
- Alberta - John Church, University of Alberta
- Saskatchewan - Tom McIntosh , University of Regina
- Ontario - John Lavis , McMaster University
- Quebec - Marie-Pascale Pomey , Université de Montréal; Elisabeth Martin , Université Laval
- Newfoundland and Labrador - Stephen Tomblin, Memorial University
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 Canadian Institutes for Health Research and Health Canada, and
- the Canadian Foundation for Healthcare Improvement for financial support in communicating and disseminating the research results.