A Cancer Control Strategy and Deliberative Federalism: Modernizing Health Care and Democratizing Intergovernmental Relations
Prince, Michael J., Canadian Public Administration
Developing the Canadian Strategy for Cancer Control (CSCC) has involved a model for conducting intergovernmental and inter-sectoral relations markedly different from executive federalism, the dominant style of Canadian intergovernmental relations since the 1960s. (1) This style refers to the dominant role played by cabinet ministers and senior public servants in managing the policy, political, and financial relationships among the federal, provincial, and territorial governments.
This article contributes to understanding contemporary intergovernmental relations and health care reform by discussing a major public health issue, outlining the features of the executive federalism and collaborative federalism models, and explicating the emerging elements of a new approach that we can call deliberative federalism. The analysis, particularly in the later sections of the article, addresses the theoretical and practical question of how federalism interacts with policy-making, reform efforts, and societal actors.
The central line of argument is that the CSCC contributes to advancing the development of Canada's health care system and federal system of governance. As a focal point for cooperation between state and social institutions, the CSCC is an inclusive network of experts and an integrated knowledge transfer system to inform policy-making and practices across jurisdictions. The Strategy supplements, rather than replaces, the traditional federal/provincial/territorial (FPT) process of meetings. It does so by respecting the primary provincial jurisdiction in health care, incorporating the full participation of non-governmental groups at decision-making tables, informing discussions and making decisions with evidence-based advice, and investing in data-gathering and knowledge transfer. The result is wide and open access to state-of-the-art prevention and management information regarding cancer care and cancer control.
Cancer control as a public policy issue
Several aspects of cancer provide an understanding of the complexity of issues and need for flexibility in public health administration and policy formation. The incidence of cancer in this country is obvious: one in four Canadians will die from the disease. (2) At least half of all cancers can be prevented by early detection, such as through reductions in tobacco consumption, increased active living, and improved healthy eating. Early integrated clinical and psycho-social intervention seems more effective than later interventions.
The causes of cancer are complex and multiple; they include individual responsibility and personal decisions as well as systemic factors of human and natural environments. Cultural values are potentially as important as the more tangible factors such as biology and the intake of toxins. Since targeting interventions is an imprecise science, public health policy needs to accommodate the testing of various models to arrive at the best treatment for the time. Individual experience of cancer patients varies by geographical region and as they progress from one disease state to another. Cancer services are highly fragmented across the country, with faulty or antiquated equipment in some places. Over the last decade, increases have occurred in waiting times for radiation therapy, chemotherapy, and other systemic therapies, with some patients sent out of the country for care. A continued lack of supportive and palliative care for patients and their families is evident.
Cancer is a major charge on health budgets. Reports both in Canada and internationally portray cancer as an epidemic or "leading killer" and as a "looming crisis" that will overwhelm the health care system in the next decade or so unless comprehensive national action is taken. The problem will most likely get worse, due to the aging of the Canadian population, among other factors. An increase in cancer patients will have a major impact on productivity levels within the older cohorts, affecting government tax receipts and expenditure associated with these age groups. …