HealthcarePapers最新文献

Over the past four decades, the most significant organizational change has been the establishment of health authorities that have been delegated by provincial governments to manage health systems. The continual changes made to the structure of health authorities, including the recent trend to more centralized administration, have caused considerable upheaval. Although a major change in the immediate future would only amplify this upheaval, it is still worth delegating to health authorities the additional responsibility for the payment and management of health human resources, including physician remuneration and bargaining. This is one more incremental change that holds the greatest promise in terms of improving accountability and health system performance.

This issue of HealthcarePapers tackles the challenging question about how to strengthen health system governance in Canada and helps to make sense of the wave of structural reforms underway across the country. The lead essay and commentaries in this issue provide the much-needed empirical and experiential evidence on the intended and unintended effects of reforms to governance, with a focus on the recent wave of centralization of regional authorities across provinces. This issue provides the necessary tools for health system leaders to maximize the potential of these new governing agencies.

Healthcare governance shapes health system performance. System leaders can redesign governance to better meet the needs of citizens and communities by strengthening collective impact. To create collective impact, we must engage patients, caregivers and the broader public to create a shared vision and invest in improvement. In this paper, we argue for governance models that enable a culture of ongoing learning and improvement aided by expanded patient and public engagement and co-design. Overarching principles combined with more power at the local level offer levers for transformation based on system integration and the insights of diverse partners and perspectives.

Looking at the feedback received on my paper on governance reforms in Canada, I was struck by the diversity of viewpoints. Some commentators were more optimistic than others and saw the importance of and the possibility of fixing governance for a better health system. Others were more skeptical, and they were certainly not alone, considering the limitations of past reforms. Being aware of the complexity of achieving beneficial governance, reforms should not deter us from efforts to better align governance with health system improvement. Indeed, critical awareness and perseverance appear through these commentaries' essential ingredients of real governance reforms.

In reviewing feedback on our article, we are reassured by the unanimity of concern about the current situation. However, there remains much oversimplification about what is meant by "public" and "private," which undermines clearer thinking and innovation in practice. The confusion that results needs all our efforts to be removed. Canada's health system today holds much-deserved pride and praise. However, preserving and sustaining those accomplishments is in doubt, due in part to drivers of population need and change, which cannot be avoided, and in part to, in our view, somewhat misplaced rigidity and misunderstanding about the current situation and options going forward. We observe greater flexibility and innovation in other high-income countries. We urge learning from those innovations with a more open mind. May these exchanges move us a bit further along that path.

Canadian healthcare consistently underperforms. The Canada Health Act (1985) is far from ideal, but it has never been the main impediment to system improvement, and updating or replacing it has limited potential to effect transformational change. It is impractical to shift from a Beveridge-style tax-funded system to a Bismarckian social insurance approach. Improvement requires better policy, incentives aligned with goals and accountability for performance. The key ingredients are wisdom and courage.

Canada's healthcare system is at a crossroads. After years of declining performance, there is growing pressure to consider more radical changes in the way it is funded and delivered, including increasing the scope of private options. But the Canadian Medical Association's engagement with more than 10,000 physicians, patients and members of the public - through surveys, town halls and focused dialogues - revealed that accessible healthcare, regardless of the ability to pay, remains a bedrock value. We need to continue the hard work of strengthening the public health system to ensure that it meets Canadians' evolving health needs.

The framework for publicly insured healthcare in Canada was established in the middle of the twentieth century with the 1957 Hospital and Diagnostic Services Act and the 1966 Medical Care Act. These statutes were consolidated in 1984 as the Canada Health Act (CHA) (1985). The key provision of this legislation was the stipulation that medically necessary healthcare provided in hospitals, or by physicians, was to be publicly insured. The point was to provide access to medically necessary healthcare independent of the ability to pay. This commentary suggests that the contours of healthcare in Canada have shifted substantially since the development of medicare and that, because of these changes, the CHA (1985) no longer facilitates either accessibility or equity. Owing to the "deep but narrow" provision of healthcare services, key aspects of contemporary healthcare (including pharmaceuticals and mental healthcare) are often not publicly insured. At the same time, because of changes in who provides medically necessary care, and where and how it is provided, many Canadians are increasingly able to access these services independently of public insurance. Somewhat paradoxically, the rigid structure of the CHA (1985) has both diminished access to publicly insured healthcare, on the one hand, and has permitted the emergence of two-tier healthcare, on the other. Achieving better access to, and equity in, healthcare provision will require a fundamental rethinking of the nexus between federal funding mechanisms and the regulatory landscape in the provincial/territorial [ PT] domain.

There is an overwhelming body of evidence documenting the failure of our health systems in Canada. Also, there are compelling comparative data showing that, despite similar challenges faced by health systems around the globe, Canada consistently underperforms relative to its peers on both healthcare quality and health outcomes.

Canadian healthcare faces a myriad of challenges. Debates focused on reform often occur within the "public vs. private" paradigm, despite a body of evidence that has largely resolved the issue. Thus, the debate is not one of evidence; it is political. Piercing this debate can occur through a return to values, operationalizing them via design and adopting an assets-based approach. Challenges to reform cannot be ignored, including recognizing material realities. No matter what form changes to the healthcare system take, considerable social and political capital will be required for reform.