Equality: A concept in Canadian health care: From intention to reality of provision

Abstract

Although it has been the intention to provide for greater equality for the health of Canadians since the 1940s through a national health insurance scheme, epidemiological data show that this intention has not been realized. Beginning with some comments on the difficulty of objective policy analysis, reasons for this failure are considered. First, the ambiguity of the concept of equality and its interpretation within a liberal political framework is discussed and then the processes of implementation of a national health care policy are examined. Different political ideologies emphasize one aspect of equality over another. Canada's dominant ideology is utilitarian liberalism challenged by an ideology of collectivist humanitarianism. From time to time concessions are made by the authorities to the challenging humanitarians when national values are set up for reconsideration in new policy cycles. The evolving nation of Canada has wanted to emphasize different interpretations of equality in different cycles of national and international social policy development. Equality of condition seemed to be an important policy to pursue in the 1940s in reaction to depression and war. Equality of opportunity has had more appeal before and since. Equity is a continuing concern in a geographically widespread country which has had to make determined efforts to hold itself together. Since health policy began to be perceived as an important means of integrating the country, a contradiction at the core of the policy has been denied. The federal government used national health insurance as a way of pursuing an equity policy, redistributing wealth to poorer provinces and regions. It was also an “equality of condition” policy, being a major “welfare state” programme. But since the dominant liberal ideology emphasizes self-help and minimal government intervention (equality of opportunity), there has always been a concern about the amount of government involvement. Yet Canadians are reconciled to the national health insurance scheme because it expresses a separateness in social policy, so in national identity from the U.S. Subsequently, using charts to explain the movement of issues through the political system in Canada, the power of governments to act is considered. Governments have regulative and distributive powers but the providers can challenge these powers, both in terms of their formal contractual relationship to the national health insurance scheme (which has its ambiguities) and in giving service to individual patients (because they have professional discretion to make judgments about appropriate care). The distinction between financial and service rationing is discussed and the implications of professional discretion for equality policies considered. Finally, it is argued that Canadian consumers will wish to build a scheme which enables them to pursue “equality of opportunity” on top of the existing scheme, which is an “equality of condition” programme. A new approach to “equality of opportunity” is likely to be to the advantage of consumers rather than providers, who were favoured in the past.