Canadian Medical Association Journal 1995; 153: 1059-1062
[résumé]
Health care services are as subject to international trends as taxation policies or education philosophies. Right now, the fashion is to reform health care by decentralization. But as distinguished British health economist Alan Maynard noted recently, "The problem is, we've never evaluated the reform. We don't even know how to measure it. Is it better because it's cheaper? Or because it provides better outcomes? Or simply because it's different from whatever went before?"
Maynard, professor of economics and director of the Centre for Health Economics at England's University of York, was speaking at the recent Queen's--CMA Conference on Regionalization and Decentralization in Health Care. The first day of the well-attended 2-day conference was spent looking at experiences with regionalization and decentralization -- two words that are sometimes used synonymously and sometimes separately defined -- here and abroad. With each successive speaker, the message became clearer: there are more muddled theories behind the trend and more pitfalls ahead than planners ever expected when they embarked on the exercise to decentralize.
A useful introduction to the subject was given by Jonathan Lomas, coordinator of the Centre for Health Economics and Policy Analysis at McMaster University. He provided a "taxonomy of regionalization and decentralization." A review of all the recent provincial task forces on health care reform yielded several common themes, and one paradox.
The themes included a recognition that public and community participation in health care debates should be improved, and a consensus on what improved management of the system might yield: cost containment, better health outcomes, more flexibility and responsiveness, and more integrated community services. The paradox, Lomas observed, is that all the task forces had talked about "restructuring fragmented delivery of services," which implies that there has already been so much decentralization there is a vacuum of accountability.
Other countries are looking at different strategies for reorganizing their health care services and, pointed out Lomas, using different buzzwords. In the US, for example, "managed competition" is designed to encourage competition between payers. In the UK, "the purchaser-- provider split" is geared toward providing competition between providers.
The devolved command-and-control approach adopted in Canada, in contrast, is designed to garner up some of the devolved authority of providers -- New Brunswick, for instance, has dissolved local hospital boards -- while causing some of the formal power and authority of provincial governments to flow downward. Saskatchewan and Prince Edward Island have delegated responsibility for financial allocation and service delivery to district health councils. Lomas said there are now about 116 devolved authorities across Canada. Their degree of independence varies all the way from service delivery to providing policy advice. In a few instances in British Columbia, it even includes revenue-raising autonomy.
As provinces grapple with decentralization, they face three issues: Where? What? Who? Should authority be devolved to regional or local levels, or both? How big should the scope of the devolved services be? Should they include social services and even subsidized housing, as well as health care? And whose values and what information will be used to influence the program choices and resource allocations? Those of politicians, major stakeholders, administrators and planners, or of community appointees or representatives?
Different provinces offer different models. In Quebec, for instance, the system is largely run by nonelected "experts" and both health care and social services are handled at the regional level. British Columbia has chosen to delegate some powers to the regional level and some to the local level, so there are two layers of bureaucracy reporting to the provincial ministry.
"The longer a devolved authority operates," observed Lomas, "the more tension develops between its obligation to reflect community needs and its role as central enforcer."
Provincial governments surrender power reluctantly, but as regional or local authorities pick up steam, they are more likely to let community priorities outweigh provincial ones. "There is a growing concern," said Lomas, "that elected boards will be dominated by representatives who'll say, `You can't close this hospital because it's in my town.' "
Raisa Deber, professor of health policy at the University of Toronto, raised fundamental issues about health care reform. First, why are planners talking in 1970-style terms about "community" when the information revolution has rendered the term meaningless to most Canadians? Second, why is Canada moving to a system of local control when Sweden is simultaneously abandoning such a system?
If the conference's audience of physicians, administrators and planners nursed any optimism about the process of health care reform, remarks by England's Maynard were guaranteed to kill it. Maynard, who has been an adviser to the European Community and the Organization for Economic Cooperation and Development, observed that Britain's National Health Service (NHS) is "perpetually in a state of crisis. And for the past 50 years, the political response to the crisis has been to re-disorganize."
Maynard outlined the dramatic changes in the NHS over the past decade. The British government has moved at a fierce pace to reform health care. It issued a white paper in 1989, introduced legislation in 1990, and expects to complete the turnaround by 1996. The goal was to introduce the mechanisms of the free market into the NHS and to improve productivity and eliminate duplication. But the Conservative government never introduced any form of regulation into the new health care system, despite the tight regulation of other "free markets" such as the Stock Exchange or insurance industry.
Maynard described the reform process's shortcomings with heavy irony. "When the health minister, Kenneth Clarke, was asked how much the reforms had cost, he replied, `I haven't a clue.' So he was promptly promoted to the job of chancellor of the exchequer."
Meanwhile, NHS costs have risen significantly because of the frequent cash injections required to speed the reform. Maynard argued that equity and cost control have been maintained, but it is difficult to judge whether the NHS has been improved. He said the measures the government has used to declare it a success -- shorter waiting lists and more "completed consultancy episodes" -- are too ambiguous to offer real proof.
New Zealand provides a case history of drastic reforms to the health care system that were triggered, in 1991, by a major fiscal crisis. Malcolm Anderson, an economic geographer from New Zealand who is a senior associate in Queen's Health Policy Research Unit, described changes that had shrunk the share of health care funding from taxation from 88% in 1980 to 76% in 1992. Hospitals were closed, patients faced far more out-of-pocket expenses, several layers of administration were cut while four new regional health authorities brought much more rigorous management practices to the provision of care.
Predictably, the reforms aroused strong opposition and accusations that the government was putting people's health at risk. "It was too much radical change too fast," admitted Anderson, "and the basic question -- What do New Zealanders want from their health care system? -- still remains."
However, he concluded that the first lesson from such a process is that "hard decisions must be made: incremental change may not be enough."
One province that has taken such hard decisions is Saskatchewan. In 1992, the province started to reshape its health care system, as John Malcom put it, "from a cottage industry to an integrated business." Malcom is chief executive officer for the Saskatoon District Health Board, which has responsibility for all aspects of health care in the district, and is involved in health promotion, education and research. His board is the largest of 30 district health boards, which are responsible for allocating funds and delivering health care and social services in their districts. The provincial government remains their sole source of funding.
Malcom, a gung-ho salesman for the changes he implemented, described how rigorous systems analysis and cost controls have yielded savings. For instance, Saskatoon boasts three independent hospitals, and under the new regime services have been rationalized and administrations amalgamated. "We attacked a lot of sacred cows, so we've been under pressure to prove we've made a difference. But 85% of the savings have come from administration and management cuts, rather than cuts in patient care."
Malcom also argued that he could produce hard facts about improved efficiency -- for instance, meal costs have been reduced.
The underlying premise of Saskatoon's reforms is that there is already enough money in the health care system so, in Malcom's words, "there is no excuse for misallocation." The same premise underlies reform initiatives in New Brunswick and Quebec, which were also described at the conference. New Brunswick abolished all its hospital boards, established eight regional corporations with consolidated administrations and medical staffs, and expanded by 20% its ambulatory health services. Quebec took a different approach, devolving powers to local rather than regional levels. In each case, however, reform was unpopular because jobs were lost and local facilities closed.
Canada's largest province has proved the most resistant to change. Alan Warren, who was executive director of the Ottawa-Carleton Regional District Health Council from its formation in 1975 until his retirement this year, remains sceptical about Ontario's all-too-modest attempts to devolve power from Queen's Park to district health councils. He suggested that the pendulum may have begun to swing against regionalization. The new Tory government elected in June may feel little incentive to join the regionalization bandwagon.
Although fiscal pressure may be the ostensible reason for most reform initiatives around the world, politics is usually the engine. No one made this point more forcefully than David Peterson, the former premier of Ontario and now a lawyer practising with a large Toronto firm. He opened the conference with some reflections on medicare as a national institution. Referring to the recent triumph of the Ontario Conservatives led by Mike Harris, he suggested that many Canadians now cherish different political principles than those his government represented between 1985 and 1990.
The hot buttons for the provincial Tories were their pledges to lower taxes and provide less government. "This means," said Peterson, "that we must have a major philosophical discussion about what's worth saving in our system, and what isn't. I happen to believe in medicare as the embodiment of the principles of sharing, equity and diversity Canada represents. But I'm over the hill, and my core values are not necessarily the core values of today."