Paradigm Freeze: Why It Is So Hard to Reform Health-Care Policy in Canada

By Fierlbeck, Katherine | Canadian Public Administration, September 2014 | Go to article overview

Paradigm Freeze: Why It Is So Hard to Reform Health-Care Policy in Canada


Fierlbeck, Katherine, Canadian Public Administration


Paradigm Freeze: Why It Is So Hard to Reform Health-Care Policy in Canada

Edited by HARVEY LAZAR, JOHN LAVIS, PIERRE-GERLIER FOREST, and JOHN CHURCH.

Montreal and Kingston: McGill-Queen's Press for the Institute of Intergovernmental Relations, 2013. Pp. xvi, 398, bibliographic references.

Federal states pose particular problems for the analysis of health policy. The question of why health care takes the particular form it does has led to the efflorescence of comparative health policy in the past two decades; yet, to the extent that comparative political analysis demands that "like be compared to like," much cross-state policy analysis has occurred at the national level. This presents a significant complication when substantive health policy decisions are made at a substate level. The conventional wisdom of comparative health policy is that, ceteris paribus, federalism is a major causal factor in determining health reform (or the lack thereof) due to the powerful conflicting interests and multiple veto points that characterize federal states. Notwithstanding the point that, in comparative analysis, all things are rarely equal, "federalism" has generally remained a key variable in the explanation of why health care reform in Canada is so difficult to achieve.

The first notable point of this new volume, then, is its claim that the institution of federalism in and of itself is simply not that important when understanding the reasons for stasis in Canadian health policy. Part of a larger academic trend investigating policy analysis from a more regional perspective, Paradigm Freeze argues that the explanation for the "meagre" results in health care reform from 1990 to 2003 can be understood more fully by examining province-specific events. These include, inter alia, specific political interests (such as provincial physician and hospital associations), the fiscal health of a province, the particular political, cultural and institutional history of each region, the relative strength of a governing party, the relationship of each provincial government with its public service, the number (and urgency) of issues competing with health care on the political agenda and, of course, the political will of the government in power.

The second notable point about this volume is that, from a methodological point of view, it may be the best book on Canadian health care ever written. The substantive problem of any comparative policy analysis is the tension between getting the detailed accuracy of each case study right, on the one hand, and finding interesting and theoretically remarkable patterns between case studies, on the other hand. Too much emphasis on the first point and one ends up with a very meticulous explanation of why something happened in one specific case at one particular point in time, giving one a very accurate understanding of political causality, but little ability to generalize across cases in such a way as to provide interesting theoretical observations about health reform in general. Too much concentration on what is common to all or most case studies, in contrast, permits general theories to emerge but often does so at the cost of making them superficial, predictable, and uninteresting.

Rather than choosing one approach over the other, Paradigm Freeze addresses the question of why so little health care reform has occurred from both of these standpoints. Five case studies (Alberta, Saskatchewan, Ontario, Quebec, and Newfoundland and Labrador) are dissected by contributors to this volume. Each team was given a specific set of causal questions to answer: why did a province establish (or fail to establish) health regions, needs-based funding, alternate payment plans for physicians, for-profit delivery systems, wait-list management systems, and universal drug plans? Using Kingdon's popular model of policy development, the researchers track how these policies successfully or unsuccessfully made it through the stages of landing on the governmental agenda, getting selected for active discussion, and finally being targeted for substantive implementation. …

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