health care in a highly decentralized federation the case of canada
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Health Care in a Highly Decentralized Federation: The Case of Canada. Gregory P. Marchildon, Ph.D. Johnson-Shoyama Graduate School of Public Policy, University of Regina, Canada Symposium on Decentralization of Health Care: Reform of Belgian Health Care

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health care in a highly decentralized federation the case of canada

Health Care in a Highly Decentralized Federation: The Case of Canada

Gregory P. Marchildon, Ph.D.

Johnson-Shoyama Graduate School of Public Policy, University of Regina, Canada

Symposium on Decentralization of Health Care: Reform of Belgian Health Care

Sponsored by Flemish Physicians Association: Vlaams Gennesheren Verbond

Brussels, Belgium, 18 October 2008

overview of presentation
Overview of Presentation
  • Nature and origins of political and health system decentralization
  • Some health service differences among provinces
  • Decentralization and language of health care delivery
  • SWOT analysis of decentralization
public universal system
Public Universal System
  • Medicare: universal hospital + medical care services
    • Narrow (40% of THE) but Deep (no user fees or co-payments)
  • Defined as medically necessary or medically required services
  • Funded by both orders of government
    • 75% by provincial taxation – general revenue funds
    • 25% by federal government – cash transfers to provinces
  • Provincial single-payer administrations
  • National framework of Canada Health Act
    • Five funding conditions/principles: universal, portable, public administered, comprehensive, and accessible
decentralization of health services
Decentralization of Health Services
  • Do differences in health services increase over time within a decentralized system?
  • Are differences encouraged by particular forms of decentralized governance, administration or delivery?
  • Snapshot of differences in physician and hospital services in 6 more western provinces
language of health care delivery
Language of Health Care Delivery
  • Important factor in access to, and quality of, health care
  • Mainly determined by provincial governments
    • English-speaking (8) – majority with 4.2% or less with French as mother tongue (and 2.5% using French as primary language at home)
    • French-speaking (1) – Quebec with 80% having French as mother tongue and 82% using French as primary language at home
    • Officially bilingual (1) – New Brunswick – 65% with English and 33% with French as mother tongue
  • But federal government underwrites cost of providing services to linguistic minorities due to policy (and law) of official bilinguilism
quebec
Quebec
  • Motivation behind attaining greater autonomy
  • Control over culture and language
  • Control over public health care: CLSCs and regionalization
  • Montreal and “bilingual” hospitals and institutions
    • McGill University: Montreal General; Royal Victoria; Montreal Children’s Hospital; Montreal Neurological Institute; and Montreal Chest Institute
    • Jewish General Hospital
    • Saint Mary’s Hospital
    • Lakeshore General Hospital
  • Alliance Quebec and subsequent action by federal Minister of Health: $30 m investment
ontario
Ontario
  • Health Services Restructuring Commission
  • Order to close Montford Hospital, Ottawa
  • Pressure on Ontario government from civil society as well as other governments
  • Court action
  • Reversal of decision and re-investment
conclusion swot analysis of decentralization
ConclusionSWOT Analysis of Decentralization
  • Strengths
    • Freedom and capacity of provinces to innovate and experiment
    • Intergovernmental collaboration, federal spending power and balance
  • Weaknesses
    • Non-cooperative strategies of blaming and cost-shifting
    • Difficulty of setting “national” direction
  • Opportunities
    • Replace old system of cost-sharing with more effective federal-provincial approach
  • Threats
    • Increased non-cooperation and, possibly, secession
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