Towards the end of the 1980s four strong pressures were forcing the provincial governments to think about organizational change in their health care systems: (1) the continuing reduction in transfer payments from federal government ; (2) urgent questions about improving the efficiency and effectiveness of health service organization; (3) the shift in emphasis on goals from health care access to improving health status outcomes which has led to a reconsideration of the weight put on biomedical care (the need for a social model of care if outcomes are to be improved was accepted as a national policy in 1989); (4) the need to consider how best to increase community concern about individual and community health, so that lifestyle and environment issues could be addressed earlier and more continuously rather than waiting until disease struck. New human rights policies have also emphasized the need for attitude change towards greater individual responsibility and more concern for good community network supports.
It was thought that effective reform and restructuring could be achieved by bringing health services "closer to home," setting up regions which would be able to find savings by bringing together the traditional divisions in the system which had been kept separate in the provincial health departments; regions which would be able to develop health promotion ideas and would bring in community members as policy decision makers and partners in networking. But regionalization has taken many different forms across Canada so it may be useful first to consider what the provinces were changing from and changing to in developing this restructuring.
Mills and Vaughan (1987), who studied decentralization for the World Health Organization (WHO), distinguished between functional decentralization and