Decentralization of the health care system
The Canadian health care system is, by its very nature, already highly decentralized. At a national
level it is a highly devolved system, with almost all responsibility for service delivery assigned to
the provinces. This includes financial responsibility, though with assistance from the federal
government. However, provinces themselves, until recently, have been highly centralized. Most
provinces have now introduced or considered deconcentration, and to some degree, devolution of
their own systems. The reasons most commonly given for the adoption of this reform initiative are
varied and include:
· better population health
· greater cost- and spending control
· improved integration and coordination of services
· enhanced public participation and community involvement
· greater flexibility and responsiveness
· increased equity
· improved accessibility.
Canadian provinces, with only one exception, have adopted one form or another of
decentralization or regionalization as part of recent reform initiatives. Four provinces have
adopted two-tier deconcentration models, with interlocked regional authorities and local or
community health boards. Four have introduced single-tier deconcentration models (one has only
regionalized the institutional sector) while one province has used a single-tier devolution model.
While there is increasing privatization of some services, the impact of this model of
decentralization has been negligible. Most of the privatization that has occurred is at the
institutional level, with hospitals contracting out nonmedical support services such as laundry,
meal preparation, or inventory control.
Organizational structure and management 11
Despite the widespread acceptance of decentralization, three health sectors (primary care,
pharmacare and physician services) typically remain under direct provincial control in all but one
province. This province is the only one to completely decentralize the full range of health
services.
Governance of the health authorities or board has also taken on varied approaches. A few
provinces are proposing or have introduced elected boards,
while others have opted to continue to
rely on appointments from the health sector and general population. Some provinces, however,
have taken the extraordinary step of specifically excluding providers from representation on
regional or local boards. This has caused a considerable degree of consternation among
stakeholders in health care.
The introduction of these models has not been without challenges. Various stakeholders have
expressed concerns about both the implementation and effect of this reform process. These
concerns include:
· compromised equity and access
· undermined system stability
· unclear representation and accountability
· lack of local expertise/knowledge
· potential for higher administration costs
· loss of expenditure control and monopsony power
· difficulties in discharging old and establishing new boards
· negative impact on people and employees
· understanding the needs-based planning process
· a general lack of evaluation of these reform efforts.
The decentralization process is seen by many commentators in Canada as a large-scale
experiment, because of the lack of domestic and international evidence regarding effectiveness
and outcomes.
