Decentralized health systems: Efficient and equitable?
The evidence on whether decentralized health systems achieve the often espoused health outcomes of greater equity and efficiency is inconclusive. Canada is a highly decentralized federation that permits each province to enact policies that respond to local context. Yet, most provincial governments fund a “patchwork” of health providers with little system planning resulting in duplicate services, fragmented services, higher costs and poor health outcomes, which eventually lead to governance reforms typically when new governments are elected. As such, there is a clear need to better understand the efficacy of public policy to decentralize governance in our health systems.
Recent health reform policy in the province of Ontario promises higher quality care and equitable health outcomes by optimizing its healthcare system. Since 2006, Ontario’s health sector has operated under a decentralized governance system overseen by 14 regional government authorities. Following a 2015 report from the Auditor General of Ontario indicating the regional authorities fell short in containing healthcare costs and delivering consistent best-in-class services, as well as a change in government in 2018, The Connected Care Act, 2019 (or Bill 74) was enacted to restructure the province’s healthcare delivery system.
The Bill consolidated the 14 regional authorities under one umbrella and set the stage to decentralize health administration to collaborative teams of hospitals, primary care, and community-based health and social service providers, known as Ontario health teams (OHTs). There are over 50 OHTs across the province at different levels of development and displaying various organizational forms and delivery systems. OHTs are intended to evolve into community-based integrated health systems. Therefore, an emerging challenge for OHTs is to establish shared governance and create new rules of collective clinical and fiscal accountability towards community-driven population health. To date, little research has been done on the current governance challenges and opportunities within the OHTs. Additionally, the principles of Bill 74 appear subject to interpretation, and there is no formal definition of equity or efficiency in terms of its new healthcare model.
My research project in the Doctor of Business Administration program at Royal Roads University seeks to explore how OHTs across the province are interpreting the principles of equity and efficiency and how likely these aims will be achieved as they construct a new model of healthcare delivery envisioned by Bill 74. Healthcare reform is an invisible process and this research will help to illuminate the barriers and enablers to decentralizing governance to non-governmental organizations. Ontario can serve as a model for other decentralized provincial health systems, like British Columbia’s, that are seeking to advance team-based care networks. At an operational level, as Bill 74 rolls out, it gives attention to the lessons that can be learned from how community-based, collaborative health teams are integrating health services, innovating delivery pathways, and improving quality and equity through cost control. At a strategic level, it provides an opportunity for provinces to explore whether or not decentralization is a promising strategy to transform their provincial healthcare systems to improve the well being of Canadians. Stay tuned...
