Market Limits in Health Reform: Public Success, Private Failure

Louise-Hélène Trottier, François Champagne, André-Pierre Contandriopoulos, Jean-Louis Denis

Decentralization is a regulatory process, the aim of which is to maintain or establish a balance between national (or provincial) and local levels of organizations. Fundamental social choices lie at the heart of the centralization/ decentralization tension. While centralization encourages national unity through uniformity, decentralization favours diversity by emphasizing local freedoms and the right of local communities to be different. Moreover, the centralization/decentralization process is driven by three different visions of the role of the state: the liberal, the social and the communitarian. The liberal vision seeks to minimize the role of the state as much as possible and to expand individual liberties. The social vision aims to maximize the role of the state in order to establish mechanisms of collective solidarity. The community vision tends to minimize the role of the state while at the same time increasing freedom of choice for local communities.

In the first section of this chapter, we analyse the process of regionalization in the health sector as a mean of regulating the division of power within society and as a mechanism allowing this regional structure to take its place within the state. The second section provides an overview of the evolution of the regionalization of health services in Quebec, concentrating on the most recent reforms. In the third section, we will highlight the role of the actors in the process of emergence, formulation and implementation of public policies. We maintain that at the end of the 1980s, only the community and the liberal visions of the role of the state were able to offer solutions to the management and production problems experienced by the health system in Quebec. One consequence of the present decentralization process is to modify the rules of the game which have prevailed in the health sector over the last twenty years, especially through the frequent use of democratic mechanisms by regional authorities. This is explained by the fact that Quebec opted for a decentralization process that was largely based on the community analysis of the negative effects of state centralism, an analysis which favours the self-management approach and the affirmation of differences among local communities.

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