Canada - World Health Organization Regional Office for Europe

Health systems in transition Canada 123
Canada, encouraged by policy experts and numerous commission reports,
attempted to exert some managerial control over what had been a passive
payment system. However, rationalization and the squeezing of global health
budgets in the 1990s also created the perception that services had deteriorated.
In response to voter dissatisfaction, governments substantially increased
spending on health services. Since 2000, accompanied by a large increase in
spending by Canadian governments, reforms have focused on improving the
quality and timeliness of health services.
During the 1990s, most provincial governments – in the words of one deputy
minister of health – were racing two horses simultaneously: a “black horse” of
cost-cutting through health facility and human resource rationalization and
a “white horse” of health reform to improve both quality and access through a
more managed integration of services across the health continuum, as well as a
rebalancing from illness care to “wellness” services (Adams, 2001). Cost-cutting
was accomplished, at least in part, through reducing the number of hospital beds
and health providers. In response to the reduction in the demand for hospital
care, spurred by new medical technologies that reduced the length of stay, some
hospitals were closed, others converted into long-term care facilities or wellness
centres, and still others were consolidated into larger units.
In every province, service delivery was rationalized in one form or another
in response to restrictive health budgets. In Ontario, it was achieved through
an arm’s length commission responsible for recommending and implementing
hospital consolidation (Sinclair, Rochon & Leatt, 2005) while in a number
of other provinces, it was achieved through RHAs. However, the main
purpose of regionalization was to gain the benefits of vertical integration:
that is, managing facilities and providers across the continuum of care in a
single administrative organization capable of improving the coordination of
curative and preventative services for individual patients as well as populationlevel
interventions (Marchildon, 2006; Axelsson, Marchildon & Repullo-
Labrador, 2007). This structural reform was central to the recommendations
of arm’s length commissions and task forces that delivered their reports to the
Governments of Quebec (1988), Nova Scotia (1989), Alberta (1989), Ontario
(1990), Saskatchewan (1990) and British Columbia (1991), helping create a
structural reform momentum in the 1990s (Mhatre & Deber, 1992).
There remains considerable debate concerning regionalization as a reform.
In addition, despite major improvements in data collection at the RHA level
by the CIHI, as of 2011 there had not been a systematic and comparative
assessment as to whether this structural reform has achieved its main health