Canadian Health Policy Research Articles

Research use in children's mental health policy in Canada: Maintaining vigilance amid ambiguity

Many researchers hope to see the best available research evidence used in policy-making to address important public problems. However, policy often appears to be based on anything but the research evidence, as the problem of conduct disorder (or severe antisocial behaviour in children) shows. In Canada, few children receive effective prevention or treatment programs, and incarceration is overused, despite evidence that it is ineffective and potentially harmful. Using the example of conduct disorder, we investigated why policy-making has not reflected the research evidence, examining research use in the context of competing influences on the policy process. Qualitative methods were used to analyze data from interviews with thirty-two politicians and senior civil servants. Our allegiance to rationality wavered as we listened to policy-makers who contended with the inherent ambiguity in the policy process. They told us that they managed institutional constraints including fragmentation across levels and sectors of government, and the long-term effects of fiscal restraint. They also reconciled the competing interests of stakeholders’ priorities, the public's response to negative events involving children and the media's role in shaping this response. Ideas about youth violence were morally charged, but policy-makers remained committed to improving children's lives. Day-to-day, policy-makers obtained most of their information internally and informally. Research evidence was valued and used, but as just one source of ideas and information among many. In this environment of ambiguity, creative civil servants formed partnerships with trusted researchers in order to change policy. Our findings suggest that the use of research evidence in policy-making could be enhanced if researchers learned about the competing influences on the policy process, formed research-policy partnerships, challenged the incentives within research institutions, and engaged in public debates about important problems, such as child antisocial behaviour.

Enhanced weekend service: an affordable means to increased hospital procedure volume

Decreasing waiting times for medical procedures and diagnostic tests has become a major focus for health policy in Canada. Although some commentators have called for increased infrastructure to handle the demand, building and equipping new hospitals comes with enormous costs and delays, which raises

A generative response to palliative service capacity in Canada

This paper situates a large-scale learning and service development capacity-building initiative for hospice palliative care services within the current Canadian policy context for use by international readers. In 2000 a national initiative using action research as its design was crafted to support continuing professional development and knowledge management in primary-health care environments. The Canadian health policy context is complex and requires innovative solutions to achieve desired changes in response to emerging population health demands for quality end-of-life care. Employment of educational and social science constructs, including complexity theory, communities of practice, transformative learning theory, and workplace learning methods, has proven helpful in supporting the creation of national capacity for hospice palliative care. There is a significant contribution for social scientists to make in aiding a better understanding of the complexity in health systems. At the same time, an aging population in industrial countries demands more active engagement of legal and bioethical scholars in a range of emerging policy and legislative questions about quality end-of-life care. Educational research is also required to understand better and reform curricula to prepare an emerging generation of health science practitioners for the demands of an aging population. Changing health service delivery environments demand rethinking of the knowledge and skills leaders require to influence desired change. A broader understanding of where and how learning takes place is essential for enhancing the quality of patient care. The Pallium Project represents a generative response to facilitating learning and building longer-term system capacity. The journey of project development to date illustrates some important lessons that can be adopted from hospice palliative care to inform other primary-health care initiatives, including, potentially, mental health, cardiology, diabetes, geriatrics, where productive change can result from productively linking specialists and primary-care colleagues.

Dynamics without change: Continuity of Canadian health policy

Abstract: This article reviews the major developments in Canadian health policy since the mid‐1950s and concludes with an assessment of the relevance and impact of the recent report by the Senate standing committee on social affairs, science and technology (Kirby report) and the report of the Commission on the Future of Health Care in Canada (Romanow report). The author demonstrates that hospital and medical insurance plans and the operation of Canadian federal institutions have had conserving effects on policy and politics in the health sector and that recent reforms such as regionalization of services have consolidated rather than transformed key policy‐relevant relationships. The article concludes that the principles, values and core disputes within the Canadian health policy sector in 2004 closely resemble those of fifty years ago.Sommaire:Le présent article passed en revue les grandes lignes de déloppement dans le domaine de la politique de la santé au Canada depuis le milieu des années 1950. En conclusion, il présente une évaluation de la pertinence et des répercussions du récent rapport du Comité dénatorial permanent des affaires sociales, des sciences et de la technologie (rapport Kirby) et du rapport de la Commission sur l'avenir des soins de santé au Canada (rapport Romanow). L'auteur démontre que les régimes d'assurance santé et hospitalisation et le fonctionnement des institutions fédérales canadiennes ont eu pour effets de préserver les polices et la politique dans le secteur de la santé et que les réformes récentes comme la régionalisation des services ont consolidé plutôt que transformé les relations‐clés propres aux politiques. L'auteur de l'article conclut en faisant remarquer que les principes, les valeurs et les différends fondamentaux au sein du secteur de la politiques de la santé au Canada en 2004 ressemblent étroitement à ceux d'il y a cinquante ans.

Cervical cancer mortality by neighbourhood income in urban Canada from 1971 to 1996.

The reduction of socioeconomic inequalities in health is an explicit objective of health policy in Canada, yet rates of death from cervical cancer are known to be higher among women of low socioeconomic status than among those of higher socioeconomic status. To evaluate progress toward the World Health Organization's goal of "Health for All," we examined whether income-related differentials in cervical cancer mortality diminished from 1971 to 1996. Death registration data for Canada's census metropolitan areas in 1971, 1986, 1991 and 1996 were assigned to census tracts through postal code, and the tracts were in turn assigned to income quintiles based on their proportion of the population below the Statistics Canada low-income cutoff values. We compared age-standardized death rates (using the 1966 world population standard) in the female population (excluding those in institutions) across the 5 income quintiles and calculated interquintile rate ratios (poorest over richest) and interquintile rate differences (poorest minus richest). From 1971 to 1996, the overall age-standardized cervical cancer death rate per 100 000 women (and 95% confidence interval) declined from 5.0 (4.5-5.6) to 1.9 (1.7-2.1), the interquintile rate ratio diminished from 2.7 (1.8-4.2) to 1.7 (1.1- 2.6), and the interquintile rate difference decreased from 4.6 (2.8- 6.4) to 1.1 (0.2-1.9). The income-related disparity in rates of death from cervical cancer as measured by rate ratios and rate differences diminished markedly in urban Canada from 1971 to 1996. Among the numerous factors that may have contributed to the decline (including decline in fertility and improvement in diet), one important factor was probably the implementation of effective screening programs.

Maximizing the Involvement of Rural Nurses in Policy

Rural health issues are increasingly recognized as needing attention, but many health policies in Canada are developed for the urban context and universally applied to rural settings. Addressing rural nurses' opportunities for involvement in policy will contribute to our general understanding of rural health while improving community health services. Rural nurses are in a unique position to assist because of their intimate knowledge of their communities and their position as informal community leaders. Challenges to their involvement include decreased numbers and lack of educational preparation about policy. A strength is the higher percentage of rural nurses who are managers compared to their urban counterparts. Nursing education programs need to include theoretical content and practical opportunities related to health policy. Managers need to support rural nurses' attempts in policy development by providing opportunities for membership on policy committees. Finally, once obtaining skills in the policy arena, rural nurses need to work within their communities and workplaces to help develop and implement more appropriate rural-based policies.

An examination of the self-care concept uncovers a new direction for healthcare reform.

The concept of self-care is multidimensional, with many defining elements. This paper describes the origin of this comprehensive concept. It examines the response of the nursing discipline to citizen self-care initiatives and the subsequent effects this response has had on the development of nursing knowledge. The evolution of self-care as a core concept within Canadian health policy is presented; the potential readiness fo citizens to accept self-care as an aspect of healthcare delivery is explored, identifying potential benefits and obstacles. The paper concludes with a proposed self-care approach to healthcare reform in Canada and the subsequent influence this approach may have on the discipline of nursing. The congruency between a self-care healthcare delivery system and the theoretical foundations and perspective of healthcare delivery held by the nursing discipline is discussed. The role nurses might assume in shaping a self-care healthcare delivery system is delineated.

Book Reviews Comptes Rendus

Book reviewed in this article:New Players, Partners and Processes: A Public Sector without Boundaries?:MEREDITH EDWARDS AND JOHN LANGPORDThe Trouble with Government:By DEREK BOK. Cambridge, Mass.Workfare: Why Good Social Policy Ideas Go Bad:By MAEVE QUAIDFederalism, Democracy and Health Policy in Canada:Edited by DUANE ADAMSWhistleblowers: Broken Lives and Organizational Power:By C. FRED ALFORDDécentralisation, politiques publiques et relations de pouvoir:De VINCENT LEMIEUXSkyscrapers Hide the Heavens: A History of Indian‐White Relations in Canada:By J.R. MILLERWorld Public Sector Report: Globalization and the State 2001:By UNITED NATIONS DEPARTMENT OF ECONOMIC AND SOCIAL AFFAIRS

Home care: it's time for a Canadian model.

Although all provinces and the territories offer home-care programs, Canada does not have a national home-care program, nor are public home-care services covered under the principles of the Canada Health Act. As a result, Canadians face varying eligibility, cost, quality and access issues to home-care services. Until recently, policy makers have had poor information upon which to make decisions about the role of home-care programs within the larger health-delivery system. This paper includes a review of the most recent policy relevant information about home care in Canada as well as descriptions of new models of home care in Canada and other countries. Mounting evidence of cost-effectiveness, in combination with demographic, health delivery and technological changes, are bringing home care to the forefront of Canadian health policy. Other countries are moving forward to make home care an equitable and viable option within their health delivery systems. Canada could do the same by enacting national home-care legislation in partnership with the provinces.

Medical necessity in Canadian health policy: four meanings and ... a funeral?

Four meanings of medical necessity have emerged, evolved, and dominated past and current health policy debates about the appropriate level of service coverage under Canada's health insurance program. To explore the shift in definition, provincial government and national health care association position papers responding to federal legislative and policy reviews of Canada's health insurance program from 1957 to 1984 were examined, as were more current reports on medical necessity. Four meanings of medical necessity predominated: "what doctors and hospitals do"; "the maximum we can afford"; "what is scientifically justified"; and "what is consistently funded across all provinces." These meanings changed with time as different stakeholder associations and governments redefined the concept of medical necessity to achieve different policy objectives for health service coverage under Canada's health insurance program.

Meanings in policy: A textual analysis of Canada's “Achieving Health for All” document

This paper presents a textual analysis of a key Canadian health policy document—Achieving Health for All (AHFA). It begins by establishing the importance of policy language and an interpretive approach to reveal dominant meanings and assumptions. This approach points out the significance of language and its contexts (text and intertext) and of developing a formal analytic strategy, based on semiotics. The paper concludes with a detailed, illustrated analysis of AHFA, suggesting that the document's discourse, through appealing to all, with emphases on the nation, community and all Canadians, establishes a frame of individual responsibility and rights, health promotion and broad health determinants—a frame that resonates with the cost-constrained nature of health care delivery-as found in provincial reform documents in the 1980s and 1990s.

Recent Directions in Canadian Health Policy: A Case for More Beacons

Recent Directions in Canadian Health Policy: A Case for More Beacons

Is reasonable access what we want? Implications of, and challenges to, current Canadian policy on equity in health care.

Considerations of equity in the context of health care systems are often related closely to the presence or level of prices incurred by users of health care services. Some politicians and commentators have suggested that the removal of user charges under the Canadian health care system has led to equal access to care. But it is not clear that the equity principle inferred from these claims corresponds to the equity goals of current Canadian health policy. In this article the authors identify the precise equity principle that lies behind current health policy in Canada and consider the extent to which that principle is reflected in the performance of the system. They then consider other approaches to equity in health care in the context of the stated objectives of Canadian health policy and identify the implications of pursuing reasonable access in future health policy. The authors suggest that the implications of the current equity goals have not been recognized by policy makers, and if they were to be recognized it is not clear that they would be acceptable to Canadian populations and/or policy makers. Moreover, some of the implications would appear to be incompatible with other stated objectives of public policy.

A critical analysis of recent Canadian health policy: models for community-based services.

As part of the thrust by Health and Welfare, Canada, to strengthen community health services, the National Health Research and Development Program commissioned a series of literature reviews. I undertook to review organizational models for community-based services, but said that this would be done in the context of the developing organization of the national health insurance program. With the help of colleagues I examined the literature from a number of different viewpoints. This article will present our findings on the development of policy and will trace the difficulties in making a shift towards providing more care in the community. We found that organization theories were helpful for explaining developments in the health service as a whole and the place of community-based services within it. We were able to use these theories to analyse efforts at restructuring. They provide explanations for the concurrent existence of policies of rationalization and cutbacks with policies of expansion in the area of health promotion.

Institutionalizing women's oppression: the inherent risk in health policy that fosters community participation.

Current Canadian health policy is based on the implicit assumption that women are available to provide care in the home to the dependent, the ill, the elderly, and the physically and mentally disabled. Women are socialized from birth to accept caring roles within a traditional family structure, and current societal expectations and social policy reinforce this value system. Women's health can only be understood within the context of their lived experience of social inequity, medicalization, and family caregiving. Health care professionals are complicit in sustaining women's oppression by reinforcing these institutions of social control. For health policy to be responsive to women's needs, it must be based on research that considers the social complexity of ordinary women's lives.

The politics of reform: public health insurance in Canada.

The centerpiece of Canadian health policy is a system of public health insurance covering the cost of hospital and medical services for all Canadians. The author analyzes the historical development of this policy and critically assesses its structure and dynamics. He argues that health insurance was won by Canadian workers through protracted industrial and political struggle. At the same time, health insurance was accommodated to the existing structure of power and privilege within the health care delivery system, which precluded a significant shift in the distribution of health care consumption and perpetuated the "irrationality" of a system that treats health as a problem located in the sphere of personal consumption.

A Critique of Canadian Aging and Health Policy

This paper addresses the State of health policy in relation to aging in Canada. A narrowness of the disciplinary focus of current policy analysis is criticized, and an approach based on “healthy public policy” is described and advocated. Current policy analysis is too often couched within a rhetoric of demographie crisis; it focuses too much on economies rather than social issues, and it focuses on the sick elderly instead of the well elderly. If the development and implementation of efficient and effective health and aging policies are to become a reality, organizational and institutional barriers must be overcome.

Federalism and Health Policy: The Development of Health Systems in Canada and Australia

In past 15 years, a host of cross-national studies has examined diverse approaches to economic development, social welfare, political economy, and policy making. They have typically taken economic development as their selection criterion, thus juxtaposing industrially sophisticated countries as unlike as France and Japan. The aims of these comparisons have ranged as widely as their methodologies; sometimes neither has been overly explicit. Several works, however, have gained focus by controlling for such variables as geographic size, population, or cultural similarities. By favoring depth over breadth, some have been able to justify limiting their scope to a few smaller countries like Canada, Australia, Sweden, and Argentina. Gwendolyn Gray's Federalism and Health Policy: The Development of Health Systems in Canada and is thus hardly first work to recognize multitude of parallels in scale, standard of living, political tradition, and history between Canada and Australia, but hers is among first to compare development of health policy in two Commonwealth countries. Gray, a political scientist at Australian National University, originally had intended her study as an exploration of the relationships between federalism, ideology, and social-policy development in Australia (xiv). She later incorporated Canada into her analysis in hopes of challenging assumptions about federalism, centralization, and government power that prevail among Australian political scientists, Her thesis is that development of Canadian and Australian health policy offers a singular opportunity to test orthodox and revisionist theories in federalism literature. The former, first espoused by James Madison, holds that division of power among constituent political units is a safeguard that constrains exercise of that power, at least at federal level. Canada, where decentralized federalism supposedly both retarded adoption of welfare policies and impeded dismantlement once they were in place, is a case ir point. Revisionists, by contrast, see federalism as actually facilitating growth of government by very proliferation of gov-

Health‐for‐All Policy in Canada

Recent Health‐for‐All policy in Canada is reviewed, with particular reference to Ontario. Canadian health policy has traditionally emphasised personal health services, and Canadians are proud of their national insurance programme, which covers the entire population for hospital and physicians′ services. But it is recognised increasingly that the health services must be complemented by a health promotion approach, based in the Health‐for‐All movement of the World Health Organization. The federal government has shown leadership, and several provinces are revising their health policy. Ontario in particular has established an intersectoral Premier′s Council on Health Strategy to oversee this approach, and has adopted health goals.

Finding Audiences, Changing Beliefs: The Structure of Research Use in Canadian Health Policy

The impact of research information depends on its ability to change beliefs or policy assumptions within the relevant audiences. As a hybrid of American and British systems, Canada's chosen decision-making structure for policy-making and its legislative framework for health insurance make these audiences unclear and not readily accessible. This factor and historical characteristics of the research community which made them only partially responsive to the values of decisionmakers provide an explanation for the limited past use of research information in Canadian health policy. More recently, improved responsiveness by researchers and an emerging definition of the audiences by legislative policymakers are bringing about a gradual increase in the potential impact of research at the levels of administrative and clinical policy. Because of continuing decision-making constraints on legislative policy, however, impact at this level is predicted to remain diffuse, with only cautious acceptance of the changes in beliefs implied by research.