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The Governance of Health Care in Canada

The Governance of Health Care in Canada: The Romanow Papers, Volume 3

Edited by Tom McIntosh
Pierre-Gerlier Forest
Gregory P. Marchildon
Copyright Date: 2004
Pages: 387
  • Book Info
    The Governance of Health Care in Canada
    Book Description:

    The twelve papers in this third volume of the research program for the Romanow Commission offer a detailed analysis of the governance of health care in Canada from the perspective of constitutionalism, intergovernmental relations, and societal context.

    In the first section, the authors deal with the formal division of powers regarding health care as outlined in the Canadian constitution and the Charter of Rights and Freedoms. The second section outlines the strengths and weaknesses of the intergovernmental governance of health care. Finally, the third section focuses on governance of health care outside of the governmental sphere. The theme that resonates throughout the contributions - and which is in itself a call for deeper analysis - is that health care governance has become locked in a cycle of mutual recrimination, blame assigning, and blame avoidance from the federal and provincial levels right down to the level of the individual citizen.

    eISBN: 978-1-4426-8139-2
    Subjects: Political Science

Table of Contents

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  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-vi)
  3. Acknowledgments
    (pp. vii-viii)
  4. Contributors
    (pp. ix-2)
  5. Introduction: Restoring Trust, Rebuilding Confidence – The Governance of Health Care and the Romanow Report
    (pp. 3-22)

    It should come as no surprise that the research program of the Romanow Commission on the Future of Health Care in Canada paid a significant amount of attention to the nature of Canadian federalism and the politics of intergovernmental relations, and how these relate to questions concerning the governance of the Canadian health care system. Try as one might to focus exclusively on the financing, organization, and delivery of actual health care services to Canadians, one cannot avoid running up against contending and contentious disagreements over the relative role of federal, provincial, and territorial governments in each of these activities....

  6. Part I. The Constitutional Context

    • 1 Health and the Distribution of Powers in Canada
      (pp. 25-49)

      When the Canadian union was formed in 1867, health care was primarily the concern of religious or charitable organizations and individuals. It was only gradually, and in particular after the Second World War, that the role of the State – both federally and provincially – began to expand in the field of social health. With the cost of health services on the rise, governments appeared to be a good way to provide Canada with a system of publicly accessible health services. Today, the implementation and especially the maintenance of a viable and accessible public system of quality health care remain...

    • 2 Constitutional Jurisdiction over Health and Health Care Services in Canada
      (pp. 50-82)

      This chapter examines the various questions related to the origin and exercise of constitutional jurisdiction over health care in Canada. In particular, it examines four questions that are of importance for the future of publicly funded health care. These questions are:

      1 What are the constitutional bases for the federal and provincial roles in the provision of health care in Canada?

      2 What is the constitutional basis for the exercise of the federal spending power as it relates to health?

      3 Does the Charter of Rights and Freedoms affect the distribution of jurisdiction with respect to health care and the...

    • 3 How Will the Charter of Rights and Freedoms and Evolving Jurisprudence Affect Health Care Costs?
      (pp. 83-124)

      The Charter of Rights and Freedoms, as part of the Canadian Constitution, regulates governments’ decisions about health care services. The Charter does not expressly guarantee either a right to health or a right of access to health care. However, its general rights provisions, such as equality rights, cover many aspects of the health care system. Since the Charter’s enactment in 1982, persons have brought court actions that use Charter rights to challenge health care policies.

      To date, the number of Charter challenges to facets of the health care system is not large, and the majority of them have been unsuccessful....

  7. Part II. The Intergovernmental Context

    • 4 Intergovernmental Cooperation Mechanisms: Factors for Change?
      (pp. 127-168)

      Federalism is founded on the notion of shared sovereignty, in that none of the entities forming the federation – be it the central State or the provinces, Länder or cantons – can fully lay claim to sovereignty. To achieve shared sovereignty, the power to legislate is shared between the two orders of government. A written constitution sets out the distribution of jurisdictions defining the matters on which each may legislate or, in some cases, recognizing areas where each can intervene according to certain terms and conditions.

      The famous formula devised by Daniel Elazar (1987, 12), known as self-rule plus shared-rule,...

    • 5 Roles and Responsibilities in Health Care Policy
      (pp. 169-198)

      The division of powers enumerated in the Constitution Acts of 1867 and of 1982 set the parameters of the federal arrangement in Canada. These documents reveal a tension between a centralizing tendency implied in the economic and residual powers allocated to the federal government, and the decentralizing effect of the wide-ranging responsibilities accorded to the provinces. This tension has been exacerbated since 1867 for a variety of reasons, including judicial interpretations favouring the provinces and the passage of the 1982 Canadian Charter of Rights and Freedoms. Nevertheless, periods of intergovernmental cooperation did lead to important policy initiatives, including the programs...

    • 6 Health Care Politics and the Intergovernmental Framework in Canada
      (pp. 199-223)

      The idea of citizenship is expressed in many ways. Citizens and States exchange duties and services, rights and responsibilities, in order to create workable, sustainable political communities. In Canada, as in other countries, this exchange is made visible through social policy. Benefits are accorded through pensions, education, housing, and health care as compensation for, or to enable, participation in the military, the economy, and society. Such an exchange reflects, reinforces, and generates beliefs about the Good Society and delineates patterns of social inclusion and exclusion. For Canadians, some of the substance of citizenship is revealed in the health care policy...

    • 7 The Conditions for a Sustainable Public Health System in Canada
      (pp. 224-254)

      The aim of this chapter is to answer the following question: How does a political environment geared to balancing budgets, paying down the debt, and cutting taxes impact on the preservation or sustainability of the health system? We will proceed in three stages. First, we address the notion of the health system’s sustainability and demonstrate that it depends on the system’s financial, organizational, and epistemic capacities to respond to the health needs of current generations without compromising the system’s ability to meet the needs of future generations. Second, we describe Canada’s political and economic environment and show that the forces...

  8. Part III. The Social and Legal Context

    • 8 Political Elites and Their Influence on Health Care Reform in Canada
      (pp. 257-279)

      There have been numerous and sustained calls for significant reform of health care in Canada. Commissions and task forces have recommended many changes, including service integration, user charges, primary care reform, and evidence-based practice (see, for example, for Alberta, Premier’s Advisory Council on Health 2001; for Quebec, Commission d’étude sur les services de sante et les services sociaux 2001; and for Saskatchewan, Commission on Medicare 2001). The Canadian public began to call for large changes in the health care system in the early 1990s, which was significant given the many years of being generally satisfied with the system, unlike the...

    • 9 Creating a More Democratic Health System: A Critical Review of Constraints and a New Approach to Health Restructuring
      (pp. 280-311)

      The twenty-first century opens with a fresh challenge for Canada’s health care system. In response, academics and decision-makers are spending much effort and time conceptualizing and theorizing about two closely related issues: the benefits of public participation in the planning and implementation of health care services; and how we can go from ‘here to there’ to create a more open, democratic, and effective health system in an era when globalization, corporate concentration, and efficiency concerns are a high priority and the nation-state itself is being questioned from both above and below. These revolutionary changes that are taking place have posed...

    • 10 Could New Regulatory Mechanisms Be Designed after a Critical Review of Health Technology Innovations?
      (pp. 312-345)

      This chapter was prepared at the request of the Commission on the Future of Health Care in Canada. The following question was submitted to the author: How will diagnostic and therapeutic technologies and procedures drive costs in the foreseeable future? The Commission also submitted a series of specific questions aimed at identifying technologies that may have an influence on health care and costs, the extent to which the cost of these technologies would be offset by a reduction in required services, and how expenditures could be controlled.

      Researchers who have attempted to address the issues raised by the Commission have...

    • 11 Strengthening the Foundations: Modernizing the Canada Health Act
      (pp. 346-387)

      The Canada Health Act (CHA) states that its purpose is to ‘establish criteria and conditions in respect of insured health services and extended health care services provided under provincial law that must be met before a full cash contribution may be made’ (CHA 1985, sec. 4). But to view the CHA as simply a dry and dusty spending statute, whereby the federal government transfers funds to provinces that comply with certain conditions, belies the importance of the CHA in the hearts and minds of Canadians. For most Canadians, the CHA has become a document of near constitutional status, emblematic of...