Reinvigorating Publicly Funded Medicare in Ontario: New Public Policy and Public Administration Techniques
Fenn, W. Michael, Canadian Public Administration
When elected in 2003, the new Ontario government faced a daunting health care reform agenda and a major fiscal and bureaucratic repositioning agenda, and both agendas were on an accelerated timetable. In response, the Ontario public service established a new mechanism both for developing and approving health care policy initiatives, and for implementing those initiatives once adopted. The health care reform agenda in Ontario was--and is--wide-ranging: from primary care and drug programs, to improved system performance (shorter wait rimes for key medical procedures) and institutional realignment. This experimental new mechanism--the Premier's Health Results Team (HRT)--appears to have achieved solid results and the Ontario health care system is showing signs of being on the road to recovery. The experience of the HRT also points to a potential cure for another persistent failing of public service reform efforts in a parliamentary system. The HRT model suggests a mechanism to enlist the increasingly important broader public sector in governments' own reform efforts, by using leverage within that wider system (human resources, technological, information, and finance) to enable the system to reform itself.
The evidence ... shows that delays in the public health care system are widespread, and that, in some serious cases, patients die as a result of waiting lists for public health care ...
... For many years, the government has failed to act; the situation continues to deteriorate ... While the government has the power to decide what measures it will adopt, it cannot choose to do nothing. (1)
Who makes such incendiary comments about the lack of efficiency, integration and client satisfaction with Canadian health care services? Were they special interest advocates lobbying for even more money for health care personnel and institutions, or right-wing proponents of two-tiered medicare, or the provocative editorial gibes of a metropolitan newspaper? No, these were the views of the justices of the Supreme Court of Canada in the significant Chaoulli case, also speaking--some might suggest--as typical middle-aged Canadians and potential patients.
The malaise was born, at least in part, of institutional and political neglect, heading for the political perfect storm. What were the symptoms?
--Demanding baby-boomers, who had driven public policy since the Second World War, were becoming grandparents and care-givers for elderly parents. As consumers and voters, they increasingly recognized the physiological evidence of their own impending demands on the health care system.
--The cost of remarkable new pharmaceuticals, prostheses, and medical technologies was rising exponentially, fuelled by barely sustainable government and employer drug plans.
--Direct and indirect employment in health care had become one of the largest and least fiscally constrained elements of the public sector.
With nearly half the Ontario budget devoted to health care, health expenditures were also threatening to crowd out many important social, environmental, and economic priorities. While Canadian medicare was a near-term economic advantage-in a North American context, unconstrained growth in health care costs would ultimately undermine economic performance and global competitiveness, as it was already doing in the United States.
The accumulating pressures in the system had been referred to journalistically as an "impending tsunami." One might therefore have expected at some point to have seen more urgent, focused, and collaborative action from all those within the health care system, including the governments ultimately accountable for that system. One might have anticipated a single-minded concentration on improved operational efficiency, population wellness, reduced overhead, and clinical integration. Other segments of society, and other jurisdictions, had already met the modern challenge of the demanding customer, responding with increased productivity, cost-reduction, and better use of information technology. …