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One essential role of the central government in a federation is to universalize the good--if necessary, against the will of some federated states. This function does not imply superior knowledge or exceptional experience. In fact, it does not presuppose anything but sensitivity to public opinion and a semblance of constitutional authority. The current government of Canada is less inclined than its predecessors to intervene in the health sector; one might even say that federal leadership is lacking. Yet in fact, if innovation is now at a halt in our health system, it could be less because of what the federal government is (not) doing to support national solutions, and more because of intrinsic issues of management and orientation at the level of healthcare organizations and delivery systems., (Copyright © 2014 Longwoods Publishing.)

Health care systems are under pressure to control their increasing costs, to better adapt to evolving demands, to improve the quality and safety of care, and ultimately to ameliorate the health of their populations. This article looks at a battery of organizational options aimed at transforming health care systems and argues that more attention must be paid to reforming the delivery mechanisms that are so crucial for health care systems' overall performance. To support improvement, policies can rely on organizational assets in two ways. First, reforms can promote the creation of new organizational forms; second, they can employ organizational levers (e.g., capacity development, team-based organizations, evidence-informed practices) to achieve specific policy goals. In both cases organizational assets are mobilized with a view to creating complete health care organizations -- that is to say, organizations that have the capacity to function as high-performing systems. The challenges confronting the development of more complete health care organizations are significant. Real health care system reforms may likewise require implementing ecologies of complex innovation at the clinical, organizational, and policy levels. Policies play a determining role in shaping these new spaces for action so that day-to-day practices may change.

This article focuses on Quebec's most recent reform in the regionalization of health care to understand why the government chose to transform the regional boards into agencies. This case study used interviews and documentary analysis. Rooted in a political science perspective, the conceptual framework is inspired by the work of John Kingdon (1995) and draws on the four variables that influence the choice of policy: ideas, interests, institutions and events. Results of the case study suggest that Quebec's Commission of Study for Health and Social Services (the Clair Commission) in 2000 and the 2002 pre-electoral environment put the issue on the agenda. In 2003, the newly elected Liberal government passed Bill 25 – An Act Respecting Local Health and Social Services Network Development Agencies, which represented a political compromise: originally slated for eradication, the regional tier survived but in a new form. The element that sparked reform was the change in government following the elections. Different inquiry reports spread the reform's ideas, while interest groups articulated contrasting visions on the transformation. Above all, regional institutions showed great resilience in the face of change. From a historical perspective, this regionalization policy is a step backward: the regional tier is now stronger from a managerial and technocratic point of view, but it is politically and democratically weakened. This suggests a government intention, at that time, to maintain the regional level as a means of retaining centralized control over Quebec's health-care system.

In 2002 Canadians were less anxious about the state of their health care system than they were a few years earlier, when perceptions peaked that the system needed major reform. They expressed strong support in 2002 for maintaining the status quo on health care financing (that is, no user fees and no two-tier care) within the traditional domains of physician and hospital care. But they appeared more receptive to two-tier care and for-profit delivery for the newer and rapidly expanding domains of home care and high-tech care.

This paper is centred on the use of legislation as a tool of public action in health policy. We suggest that, as with the Canada Health Act (CHA) of 1984, this option should be considered to direct future reform efforts and pursue our collective aims of health and wellness. The CHA is the legislative expression of the federal government's exercise of its spending power, serving to consolidate key national agreements governing the circumstances under which the federal government contributes to the costs of medically necessary health services delivered by the provinces and territories. Two features of the CHA merit highlighting. The first is that its core provisions -- in particular, the five criteria often referred to as Canada's "national standards" for health care -- were not new or original to the CHA. The CHA was nonetheless an important step in the development of Canada's health system because it enshrined together, in one statute, longstanding commitments. A second feature of the CHA worth highlighting is that it does not stand alone. The CHA is one of 13 statutes across the country, including one in each province and territory, that serve together to establish the basic legal infrastructure of Canada's health insurance system. The CHA's powers to make regulations and issue policy interpretation letters offer important potential to achieve needed health system reforms without needing to "open" the act. Even where these powers are unrestricted by an express requirement for consultation with the provinces and territories, however, this would undoubtedly be required, given the fundamentally consensual nature of the CHA. Finally, the federal government's legislative options are not limited to the CHA. Jurisdiction over health and health care in Canada is shared between the federal and provincial and territorial governments. The various federal powers with health aspects allocated by the Constitution Act, 1867 are significant, including the residual "federal health power" to make laws "for the peace, order and good government of Canada" It therefore makes good sense to consider federal policy objectives in the health domain with regard for the full spectrum of federal legislative competence. [ABSTRACT FROM AUTHOR]

At their origin, public healthcare systems were designed mainly for the treatment of acute illnesses. For many years, therefore, public health care focused on services offered in healthcare establishments and primary care was allowed to evolve on the periphery of hospitals, with doctors free to follow their own conception of how best to provide and follow up on care. As hospital costs grew, however, and new challenges regarding the provision of care began to emerge, governments felt increasingly responsible for organizing the front line (Nolte and McKee 2008). How doctors would be called upon to participate in the new configuration of services — particularly in Canada, where physicians function as independent entrepreneurs — is the subject of this article, which investigates the decision to introduce family medicine groups (FMGs) to the province of Quebec. [ABSTRACT FROM AUTHOR]

Gives a brief description of the process, the outcome, and the effects of the Romanow Commission on the Future of Health Care in Canada, which entailed a dialogue with representative cross-sections of the Canadian population. View that the legitimacy and sustainability of any major policy decisions depends on how well it reflects the underlying values of the public; Mention of ChoiceWork dialogues, which were created by Viewpoint Learning and based on the research of its chairman, Daniel Yankelovich; Way that the dialogues engage members of the public on important issues before the decisions are made; Impact of combining the roles of citizens as taxpayers and patients on the debate; Opinion that engaging the public in this way is more costly than polling, but is essential when making difficult decisions. INSETS: Summary points;Box 1: Basic steps in a ChoiceWork dialogue project;Box 2: Four scenarios for the future of health care in Canada;Box 3: Participants' own words (extracted from session...