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Health system reforms
Rev Bras Promoç Saúde, 31(4): 1-15, out./dez., 2018 1
DOI: 10.5020/18061230.2018.8802
Recebido em: 10/01/2018
Aceito em: 25/09/2018
HEALTH SYSTEM REFORMS IN MATURE WELFARE STATES: TALES FROM THE
NORTH
Reforma dos sistemas de saúde em estados de bem-estar social amadurecidos:
contos do Norte
Reformas de los sistemas de salud en los estados maduros de bienestar: historias
del Norte
Jean-Louis Denis
Université de Montréal - Montréal - Canada
Susan Usher
École nationale d’administration publique - Montreál - Canada
Johanne Preval
Centre hospitalier de l’Université de Montréal - Montréal - Canada
Élizabeth Côté-Boileau
Université de Sherbrooke - Québec - Canada
ABSTRACT
Objective: This article has the objective show an essay on emerging themes in health system reforms, based on experience in
Canada. Data synthesis: Reforms are the privileged mode of social change used by modern democratic societies. Persistent
dysfunction and failure to adapt to emerging health needs and priorities within health systems in Canada provide a strong
policy rationale to search for alternative strategies that might produce much-needed reforms. Three persistent challenges and
opportunities for reform in Canadian health systems are discussed: the design of eective governance arrangements, the large-
scale development and implementation of improvement and transformative capacities, and the leadership and engagement of
the medical profession in working toward broad system goals. In exploring these challenges, we identify tensions that seem
relevant to better understanding health system reform in mature welfare states. Conclusion: Addressing these tensions will
require both a reinforcement of state and government capacities and stronger capacities at all levels of the health system to
design and support change.
Descriptors: Health Systems; Health Care Reform; Health Planning.
RESUMO
Objetivo: Este artigo tem como objetivo apresentar um ensaio sobre temas emergentes em reformas de sistema de saúde, com
base na experiência do Canadá. Síntese dos dados: Reformas são o modo privilegiado de mudança social usado pelas sociedades
democráticas modernas. Disfunção persistente e deciência na adaptação às emergentes necessidades de saúde e prioridades
dentro dos sistemas de saúde no Canadá propiciam uma forte argumentação política para a busca de estratégias alternativas
que possam produzir as tão necessárias reformas. Três desaos persistentes e oportunidades para reforma nos sistemas de
saúde canadenses são discutidos: o delineamento de arranjos de gestão efetivos, o desenvolvimento e a implementação em
larga escala de capacidades de melhoria e transformação, e a liderança e engajamento da classe médica no trabalho em direção
aos amplos objetivos do sistema. Ao explorar esses desaos, identicamos tensões que parecem relevantes para melhor se
compreender a reforma do sistema de saúde em estados de bem-estar maduros. Conclusão: O enfrentamento dessas tensões
exigirá tanto um reforço das capacidades do Estado e governamentais como capacidades fortalecidas em todos os níveis do
sistema de saúde para projetar e apoiar a mudança.
Descritores: Sistemas de Saúde; Reforma dos Serviços de Saúde; Planejamento em Saúde.
Este artigo foi selecionado, corrigido e aprovado pela Comissão Cientíca do Fórum Internacional de Sistemas Universais de
Saúde, seguindo suas normas e formatação.
Fórum Internacional de
Sistemas Universais de Saúde
Denis JL, Usher S, Preval J, Côté-Boileau E
Rev Bras Promoç Saúde, 31(4): 1-15, out./dez., 2018
2
RESUMEN
Objetivo: Ese artículo tiene el objetivo de mostrar un ensayo de temas emergentes de las reformas del sistema de salud
basados en la experiencia de Canadá. Síntesis de los datos: Las reformas son un modo privilegiado de cambio social utilizado
por las sociedades democráticas modernas. La disfunción persistente y el fracaso para adaptar las necesidades y prioridades
de salud dentro de los sistemas de salud de Canadá aportan una política racional fuerte para buscar estrategias alternativas
que puedan producir las reformas necesarias. Tres desafíos persistentes y oportunidades para la reforma en los sistemas de
salud de Canadá son discutidos: el diseño de acuerdos de gobierno efectivos, el desarrollo e implementación en larga escala
de mejoría y capacidades transformativas y el liderazgo y compromiso de la profesión médica en trabajar hacia los objetivos de
sistema amplio. Explorando estos desafíos hemos identicado tensiones que parecen relevantes para una mejor comprensión
de la reforma del sistema de salud en los estados maduros de bienestar. Conclusión: Direccionar estos desafíos necesitará un
refuerzo de las habilidades del estado y del gobierno y habilidades más fuertes en todos los niveles del sistema de salud para
diseñar y apoyar el cambio.
Descriptores: Sistemas de Salud; Reforma de la Atención de Salud; Planicación en Salud.
INTRODUCTION
Canada is a decentralized federal state, where responsibility for planning, delivering and funding the health
system falls primarily to provincial and territorial jurisdictions. In this paper, we explore health reforms undertaken
since the mid-1990s in various provinces to reveal challenges and opportunities faced by so-called public healthcare
systems in mature welfare states. A noted Canadian political scientist and commentator on health system reform
perceived, in her comparative analysis of health systems in high-income countries, a move away from ideal types
(Beveridgian, Bismarkian) toward more hybrid systems that enable political and institutional entrepreneurs to play a
greater role in driving change and innovation.
The mature health systems were created in the golden age of the welfare state and now have to adjust to a new
set of pressures and contingencies. In addition, she suggested that Canada has greater diculty bringing about
signicant changes or reforms than countries such as the United Kingdom (UK) and The Netherlands, due to factors
such as the bilateral monopoly over health policies held by government and the medical profession.
In a book published in 2013, another group of political scientists and health policy analysts concluded that
Canadian jurisdictions were unable to implement signicant health reforms due to a particular conguration of political
institutions, pressures and resistance. Together, these factors were seen to create a form of endemic inertia they
labelled Paradigm Freeze(1). In this paper, we explore the content and dynamics of reforms in the health systems
of a number of Canadian provinces to better understand the interplay between change and inertia that seems to
characterize their trajectory.
This article has the objective to show an essay on emerging themes in health system reforms, based on
experience in Canada.
DATA SYNTHESIS
Context and experience of reforms
Canada is a high-income country according to criteria used by the World Bank. In terms of health spending,
Canada ranked 7th among selected Organization for Economic Co-operation and Development (OECD) countries in
2015, with total spending on health equal to 10.4% of Gross Domestic Produtive (GDP), or $5,782 per capita. The
public-sector share of total spending is 70.4%, which is somewhat lower than the OECD average(2). The population
of Canada is now at 36.7 million, distributed unevenly between provinces, from just 152,000 in tiny Prince Edward
Island, to 14.1 million in Ontario, the country’s largest province(2).
Reforms are the privileged mode of social change used by modern democratic societies(3). In the context of this
paper, reform is dened as deliberate changes to the structures and processes of public sector organizations with
the objective of getting them (in some sense) to run better(4).
Whether or not the benets anticipated from reform are achieved is highly dependent on how policy ambitions are
supported and implemented by government, public organizations and non-state actors. Health care is characterized
by complex social and political dynamics that make government intervention more or less possible or legitimate(5). In
Health system reforms
Rev Bras Promoç Saúde, 31(4): 1-15, out./dez., 2018 3
addition, reforms are not the sole purview of policy-makers(6,7) they also emerge from a dispersed set of policy actors
that structure a market of ideas, where broad doctrines and techniques are promoted in a more or less coherent way(4).
Reforms of healthcare systems are on the political agenda in all OECD countries and include a wide range of
policies aiming to improve healthcare delivery systems, optimize the use of resources and advance population health.
The scope of these policies varies according to the institutional tradition of each country, their transformative capacities
and the specic challenges they must address. Canada is no exception, undertaking multiple reorganizations and
reforms, conditioned by predominant political ideologies, to respond to pressing contingencies. As with other countries,
controlling costs is a major preoccupation. In Canada, growth in healthcare spending has slowed after reaching a
peak of 11.6% of GDP in 2010, decreasing by an average 0.2% per year between 2010 and 2014(8).
While cost control is an important objective, it is not synonymous with delivering eective and appropriate care(9,10).
Reports and analyses in the last 15 years suggest that substantive change remains elusive in Canada(10-15).
A recent report commissioned by Health Canada(16) suggests the need to renew the Canada Health Act of 1984,
which provides the federal framework for healthcare policy across the country, in order to promote national programs
to support a data-driven health system and meet needs for home care, mental health care and aordable drugs. The
viability of this federal policy agenda will rest on the political will of the provinces and territories, and on their ability to
cover the cost of new programs or expansions to public coverage in existing programs. While Canada’s jurisdictional
structure presents particular challenges, some international observers argue that it will be very dicult to signicantly
transform public healthcare systems generally(17,18), suggesting that Canada’s challenges are not exceptional.
Persistent dysfunction and failure to adapt to emerging health needs and priorities
(10)
within health systems
in Canada provide a strong policy rationale to search for alternative strategies that might produce much-needed
reforms. A recent book on the experience of health reforms in Ontario nds that health systems struggle to achieve
systemness but have never fully succeeded the trajectory of system building continues to be distressingly at. In
addition to the political challenge of change, many key policy issues have yet to be discussed, much less settled, by
the governments that must take responsibility for governing our healthcare system(19).
Policy uncertainties in Canadian healthcare systems(12) are stimulating a new wave of reform initiatives in various
provinces, oering a unique opportunity to learn from dierent attempts to transcend the paradigm freeze. In this
paper, we explore these reforms in order to better understand the challenges in bringing about change and the
opportunities that appear promising in recent eorts.
Persistent challenges and opportunities for reform in Canadian health systems
Governance for health system performance and population health
Governance has been an enduring theme in the Canadian health policy landscape. Governance involves balancing
the multiple conicting logics and interests of patients, sta, citizens, and politicians as well as other stakeholders(20)
while focusing on improving access, quality and outcomes, and has dierent scope and focus at micro, meso and
macro levels(21,22).
During the 1990s, nine of the 10 Canadian provinces created some sort of regional governance bodies, called
Regional Health Authorities (RHAs)(23). The assumption was that RHAs would increase capacities to adapt health
systems to regional realities and better respond to population needs. RHAs were expected to eectively mediate
between central government policies and local priorities: Canada’s geography creates signicant dierences between
healthcare priorities in urban, rural and remote areas, concerns that informed the creation of RHAs as governance
bodies.
In most provinces, the creation of RHAs in the 1990s was accompanied by the dissolution of the local governing
boards of healthcare delivery organizations and was likely seen by local communities as an increased centralization.
For central (provincial) governments, it spelled decentralization to an intermediate level of governance within the
health system. The impact of this movement toward regional structures is the subject of much debate(24,25) and the
question remains unsettled.
Some authors
(26)
have argued that RHAs often played the role of buer between the austerity policies of provincial
governments and the local delivery of health and social care. In periods of severe budgetary cutbacks, RHAs may
have helped to limit the damage by undertaking reorganizations that were somewhat coherent with local realities.
In Canada, RHAs appeared as new players within the governing apparatus and were ultimately an instrument of
provincial government. The recent history of health reforms in Canadian health systems supports this interpretation,
as it has underlined the fragility of RHAs as a governing structure.
Denis JL, Usher S, Preval J, Côté-Boileau E
Rev Bras Promoç Saúde, 31(4): 1-15, out./dez., 2018
4
In the early 2000s, a number of provinces reduced the number of RHAs and, in 2008, the province of Alberta
became the rst to move away from regional governance altogether, abolishing its nine RHAs and creating Alberta
Health Services as a single governing board for its health system. The consolidation was justied by arguments
that it would increase eciency, enable linkages across various resources in the system (notion of systemness) and
facilitate a more managerial and less politicized approach to running the system. Alberta Health Services (AHS) is
responsible to the Ministry of Health for delivering health services to the province’s population, but is, in principle, less
susceptible to political interference. The ambition of de-politicization in the governance of health systems somewhat
reects the penetration of New Public Management (NPM) ideas(27) suspicious of the expansion of the bureaucratic
apparatus of the state and concerned about redundancy. Reducing the number of levels of governance within health
systems satised a perceived need to control the expansion of public bureaucracies and for politicians to increase
their sense of control over the health system.
It is dicult, at this stage, to clearly assess the benets of centralization and consolidation of governance
structures in Canada’s health systems. For example, the creation of Strategic Clinical Networks (SCNs) under AHS
in Alberta has increased the coordination and appropriateness of care in some key clinical areas and is considered
a very positive experience(28).
Clinical governance as a lever to improve health systems
While governments in Canadian provinces have privileged reorganization and restructuring as a form of intervention
in health systems, we see a growing trend toward diversifying the levers and instruments for transformation and
improvement. In this section, we will discuss one of these levers, clinical governance that appears to be gaining
ground in the reform eorts of a number of provinces. Clinical governance involves processes that connect clinical
practice more explicitly to the organizational context and are aimed, on one hand, at fostering the creation of an
organizational environment that develops professional practices and, on the other, at operating directly on professional
practices to ensure better quality of care(29).
Clinical governance is based on the assumption that there are, in any health setting, latent capacities that can
be harnessed to generate improvements. By focusing eorts on the level of clinical settings, health system reformers
can access resources and processes for improvement that are not available through interventions restricted to meso
or macro system levels
(22)
. These approaches are rooted in work on clinical microsystems
(30)
, high-performing clinical
units(31,32), high-performing health systems(33), and collaborative quality improvement in health care(34-36).
For example, the Canadian Foundation for Healthcare Improvement (CFHI) partnered with organizations in a
number of provinces to experiment with collaborative improvements. These initiatives could be conned to local
settings, or developed as province-wide initiatives, such as projects aimed at reducing the use of antipsychotics in
people with dementia in long-term-care settings(37).
Another example is the growing interest in the development of strategic clinical networks (SCNs) and health
quality councils across Canada. Alberta Health Services has promoted the development of SCNs in various sectors
of care since 2012. SCNs are the mechanism which AHS is using to empower and support physician and clinical
leaders in both AHS and the community to develop and implement evidence-informed, clinician-led, team-delivered
health improvement strategies across Alberta. SCNs will also focus on leading and supporting evidence-informed
improvements in team-delivered prevention and in clinical performance to achieve the highest quality and best
outcomes at the lowest reasonable costs(38).
To date, the province has created 15 SCNs in areas ranging from cardiovascular disease and stroke, to public
and indigenous health, with two further SCNs expected in 2018. Cumulative eects show cost savings along with
better access and/or quality of care. For example, improved practice in the Bone and Joint has ensured that people
are mobilized quickly following hip and knee surgery, allowing them to return home sooner and prevent readmissions;
the eort has freed up over 50,000 hospital bed days since 2009(39).
Another trend apparent since the turn of the millennium involves the creation of health quality councils in ve
of the 10 Canadian provinces, namely British Columbia, Alberta, Saskatchewan, Ontario and New Brunswick
(16)
.
These agencies, which operate at arms’ length from provincial government, aim to support health providers and
organizations in achieving better care and higher performance. Quality councils are expected to contribute expertise
and tools to healthcare delivery organizations and front-line providers to help them adapt to new demands and
increase their capacity for improvement. The development of quality standards is often accompanied by training
programs in improvement methodologies and coaching of clinicians in dierent care settings. In Saskatchewan, the
Health system reforms
Rev Bras Promoç Saúde, 31(4): 1-15, out./dez., 2018 5
Health Quality Council played a lead role in introducing approaches such as The Productive Ward – Releasing Time
to Care, and in training the healthcare workforce in Lean improvement methodology(40).
While it is dicult to assess these agencies contribution to health system improvement, they reveal a growing
preoccupation with creating a facilitative context for improvement rather than relying on more coercive approaches
(41)
.
In addition, as observed in many health systems in high-income countries
(42)
, we see in Canadian provinces an
expansion of health networks such as SCNs to compensate for the limited ability of central governance structures
to achieve coordination in the health system.
The medical profession and prospects for innovation in health policies
The question of physician engagement, leadership and accountability is an enduring issue in health policy and
reforms(31,43-45). Medical doctors play a crucial role in determining the allocation and utilization of resources in health
systems, and in shaping capacities to renew policy orientations and models of care. The status of the medical
profession and the bilateral monopoly between state and the profession have been underlined as a major cause of
blockages in health reforms in Canada(1).
The theme of medical leadership and engagement surfaces in various forms and through a variety of initiatives
across provincial health systems in Canada and at national level. For examples, the Canadian Medical Association
has, since 1999, oered physicians a training program in leadership
(46)
. The province of British Columbia has
developed a Facility Engagement Initiative to support physician participation in hospital improvement eorts, along
with a Physician Quality Improvement Initiative to support physicians in leading quality improvement projects(47).
In addition, there have been major eorts in the last 15 years to restructure primary care and more specically
to develop the role of general practitioners in the health systems of various provinces(48). Important investments
have been made in Ontario and Quebec to create and support primary care groups, with the objective of increasing
access to family physicians. While these initiatives have provided positive results on access to family physicians for
the general population, the cost of these projects and their still uncertain impact on access to care and continuity of
care, specically for the more vulnerable segments of the population, remains an issue(49) .
In Manitoba, the Physician Integrated Networks initiative focuses on fee-for-service (FFS) physician groups to
facilitate systemic improvements in the delivery of primary care: all participating clinics receive funding based on quality
performance targets(50). Quality-based improvement funding (QBIF) was introduced in Manitoba as an opportunity
to experiment with a blended model of physician compensation, mixing pay-for-performance with fee-for-service(51).
Our objective here is not to provide an exhaustive list of initiatives that support an expanded role for the medical
profession in transforming and improving health systems in Canada. Suce it to say that an important part of the
healthcare budget in Canada (15.4% as a national average) goes to services provided by general practitioners and
specialists. Payments to physicians grew at an annual rate of 6.2% over the decade to 2014, with growth slowing to
just over 3% each year since then(8) and governments are still struggling to nd ways of getting the best out of these
resources. In the years to come, this issue will continue to present a major challenge to health reformers in Canada.
Despite the fact that they are paid with public money, the status of medical doctors as independent entrepreneurs
may limit the ability to fully recognize that medicine is, in the end, a public service profession(52).
The medical profession in Canada also exerts signicant inuence on what other health professionals can do in
the health system. Rules around scope of practice and funding for education and positions within the health system
are important levers for change. Signicant variations between provinces in the use of nurse practitioners provide
an indication of government nesse in negotiating with physician interests that might fear a potential loss of terrain.
In 2016, 57.3% of all NPs in Canada were working in Ontario (n=2,769), while only 7.9% were in place in Québec
(n=380)(53).
Variations are also seen in the scope of practice allowed for other healthcare professionals: while most provinces
now allow pharmacists to switch or adjust dosages independently, only a few allow them to initiate a prescription under
delegation
(54)
. Several provinces are experimenting with advanced paramedics to provide care for rural residents
with chronic conditions. Physician assistants, who have an important place in comparable health systems such as
the UK, were endorsed by the Canadian Medical Association in 2003, but are still not commonly integrated into the
health system: only four provinces now have physician assistants in practice, and only two provinces oer training
programs(55).
Exploring the politics of health system redesign in mature welfare states
In the section above, we identify three policy challenges that emerge from attempts to reform health systems in
Canadian provinces. These involve the design of eective governance arrangements, the large-scale development
Denis JL, Usher S, Preval J, Côté-Boileau E
Rev Bras Promoç Saúde, 31(4): 1-15, out./dez., 2018
6
and implementation of improvement and transformative capacities, and the leadership and engagement of the
medical profession in working toward broad system goals. In this next section, we will explore a set of tensions that
seems relevant to better understanding the challenges of health system reform in Canada. As in our discussion of
the policy challenges above, the tensions we highlight are not meant to be exhaustive, but rather illustrate and help
to interpret some of the key issues at the heart of reform dynamics.
The tension between centralized and decentralized approaches to governance in health systems
Authors(20) argue in favour of a health system governance approach that departs from the traditional command-
and-control model, which, in generic terms, resembles traditional public administration governance where control
over the system and policy capacities is located within central government. Reformers from various ideological
and theoretical standpoints have challenged centralized models of governance. Ideas about NPM have inltrated
discourse and practice in public management in many jurisdictions(56,57).
In Canada, concerns about cost control and the size of government and the public service have prompted calls
for stronger managerial capacities to improve eciency. Such demands have often been framed in very conservative
political terms, and confound the need for managers to gain in adaptability with a drive to limit state and government
involvement in health care and others sectors
(58,59)
. From a conservative standpoint, the fundamental assumption
here is that government necessarily fails to provide ecient and eective services
(60)
because of its tendency to grow
and overspend in the absence of competition(61).
Scholars interested in reinventing government(62) suggest that a signicant renewal of policy instruments based
on the private sector, such as contracting out and public-private partnerships, will help renew the health system.
While critics of the NPM approach have been very vocal, there is a social demand to increase the capacity of public
healthcare systems to respond to challenges of an aging population and the anticipated costs of new sophisticated
health interventions (genomics, precision medicine, technological innovations such as sophisticated surgical robots).
An alternative approach to NPM in countering command-and-control-style governance involves decentralization
through network governance or policy networks(56,57,63). This trend is based on a more progressive political ideology
and promotes elements of Third Way political thinking that became fashionable in the early 2000s. From this
perspective, the centralization and consolidation of governance authority observed in recent health reforms in many
Canadian provinces are in tension with network governance that emphasizes the notion of distributed capacities in
health policy-making. A network approach to governance recognizes central government’s diminished capacity to
design and drive policies that are crucial to health system evolution: government no longer has a monopoly on the
knowledge and competencies required to push adaptation. According to this model, organizations and actors within
society are interdependent, and no one body can pretend to have all the resources (cognitive, political, operational,
etc.) needed to solve key policy challenges.
Policy capacity thus requires contributions from non-traditional policy actors
(64)
. In a network perspective, polycentric
governance becomes the norm, and the challenge is to eectively articulate the roles and responsibilities of these
various entities and organizations in reforms(65).
Both NPM and network governance models challenge the relevance of developing centralized authority to
govern health systems. However, more centralized forms of governance may present opportunities for greater
policy coherence. For example, broad policy goals such as improving population health are probably consistent
with a more centralized approach that ensures equity in resources allocation and transfers some resources from
the medical complex to population health interventions
(66)
. A centralized approach may also increase capacity to
spread and scale up innovations, invest in capacity development, and use strategic intermediary agencies such as
health quality councils.
There is no denitive solution to the dilemmas of adopting more concentrated or more distributed approaches
to governance, and this may explain the long-standing interest in public administration and political science for
the balance between centralization and decentralization in policy making. One might argue that a strong central
government, committed to supporting the public healthcare system, will be in a better position to support policies that
aim for greater redistribution towards those with greater needs. However, the benet of centralized forms of authority
probably has to be balanced with strong policy and operational capacities at other levels of the health system. In
addition, the complexity of contemporary social and policy issues means that models of collaborative governance(67)
may appear more eective. In the end, the challenge for reformers is to reconcile strong policy capacities of central
governments and states with a more open and collaborative approach to governing health systems. This dilemma
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Rev Bras Promoç Saúde, 31(4): 1-15, out./dez., 2018 7
is also related to another tension evident in Canadian health systems around the reconciliation of micro and macro
governance dynamics.
The tension between micro and macro scale in health system change and improvement
A former Minister of Health described the Canadian health system as a land of pilot projects. There are many
pockets of excellence and innovative experiments, but persistent challenges in achieving large-scale change. On the
one hand, the challenge involves learning from local experience and understanding the implications of developing
these innovations or improvement eorts into system-wide changes(68).
On the other hand, the challenge is to mobilize the authority of central governments to stimulate the adoption,
implementation and spread of innovative policies and delivery strategies across the health system. It is important
to remember that these innovative policies aim to change the way health resources are distributed and used. For
example, recent emphasis on providing care in the community and enhancing primary care has been accompanied
by a signicant reduction in the growth in hospital spending in Canada. Where hospitals represented around 40%
of total health expenditure in 1990, in 2017 they accounted for 28%. Physicians remain quite stable at around 15%,
with a slight rise evident since 2005, and drug expenditures account for an ever-larger share, rising from about 10%
of total health expenditures in 1990 to 16.4% in 2017(2).
On the other hand, we see that, despite the increasing attention to mental health as a priority, provincial spending
on mental health as a proportion of total public health expenditures actually dropped between 2003 and 2013, from
5.4% to 4.9%, with signicant variations between provinces
(69)
. The shortfall in home care is equally important: a
recent national action plan for home care advocated by national associations of nurses and physicians considered
that home health care and support services should account for 10% of total public health expenditures; in 2013, it
was only 4%(70).
A major obstacle to innovation and reform appears in the diculties central governments (both federal and
provincial) face in allocating sucient resources to priority sectors such as primary care, home care and mental health
care. This persistent challenge has prompted increasing calls to renew the Canada Health Act in order to expand
public coverage to areas beyond medically necessary care provided by physicians or in hospitals(16).
This is symptomatic of growing recognition of the political substrate of large-scale system change. After 25
years of provincial and pan-Canadian experiments, the current call for broader systemic change recognizes that
signicant improvement requires more than the dissemination and scale-up of local innovations. However, producing
and sustaining large-scale change demands a balance between policy determination and clarity, and the ability to
adapt and execute these policies at all levels of the system(71).
Based on the three policy challenges described above, policy work to rebalance the health system appears
unavoidable, and demands that we look at the health system as a political-economic machine that is largely drive by
patterns of interest(72) and by path dependency(73). The center of gravity of Canadian health systems around medical
and hospital services, coupled with vested interests, institutional sedimentation and growing population expectations
for access to innovative health technologies make real reforms dicult to achieve.
The tension between innovation and regulation
There is a wide consensus that health systems and organizations in Canada demonstrate a limited ability to
adapt, innovate and improve at a sucient pace(74 -78). This leads to a particular tension for healthcare communities
who invest a lot of energy in attempting to increase the impact of innovation within and beyond jurisdictions. In the
previous section, we focused on political obstacles to reform. In this section, we look at how policy capacities at the
central level can support the development of ecologies for innovation(79) at meso and micro system levels. In order to
address this issue, we need to renew our perspective on how these levels (macro, meso, micro) interact with each
other to defuse the tension between innovation and regulation.
The unpredictable adaptation journey of innovation
It is hardly new to suggest that the innovation journey is unpredictable, as many scholars have already
explored this phenomenon(80-84). However, what remains less explored is the dialectical relationship between how
the substance of innovation adapts to regulations set at the central (macro) level, and vice versa, and how these
adaptations trickle down through the system (to meso and micro levels). To shed the light on this issue, we will look
at the competing forces that surround innovation in health policy dynamics.
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Rev Bras Promoç Saúde, 31(4): 1-15, out./dez., 2018
8
In health care, as in others policy sectors, evidence around the substance and the benets of an innovation
competes with other forms of knowledge, such as experiential knowledge, ideologies and values, and more broadly
with patterns of interests(85). Many years ago, author(86) considered that innovation was more likely to succeed if it was
perceived as: (1) advantageous relative to current practice, (2) compatible with work context, (3) had a manageable
level of complexity, and (4) provided opportunities for trial -and error.
Some authors consider that regulations at the policy level may reduce the importance of these conditions for
success and accelerate the journey of innovation within the system(87,88). Because of the pluralist and heterogeneous
nature of health care, it may be important to maintain a balance between policy-driven innovations and local dynamics
of change and innovations(89). The ability to adapt innovation therefore becomes crucial.
Recent literature on the spread and scaling-up of innovations supports the idea that local adaptation allows
for delity to the innovation through the implementation phase, and fosters its sustainability over time(90-93). In this
regard, sociologists of science
(94)
and organizational theorists
(95,96)
have emphasized the importance of paying
attention to how practices are shaped by context and interactions that inuence the ability of a given milieu to adopt
an innovation and adapt it to evolving contingencies. According to this work, the ease of adopting an innovation will
vary, and strategies to bridge groups and organizations with divergent views appear crucial(97-105).
Agency and innovation in health systems
While work on innovation highlights the importance of local adaptation and contextualization, analysis of institutions
suggest that actors may have diculty adopting and implementing innovations. Many authors have explored the central
question: how is it possible for individuals within an institutional environment that seeks to strengthen continuity and
compliance, to innovate and think about new ways of doing things and institutionalize them?(106-10 8)
This question has been referred to as the paradox of embedded agency in institutional analysis
(109,110 )
. To overcome
this paradox, scholars looking at both industry and public sectors(111,112 ) have examined attributes of context that
favor innovation. Without going into too much detail, this body of work identies a set of conditions that supports
the innovative work of actors in highly institutionalized settings such as health systems. Among these conditions,
they underline the opportunity for agents to experiment with alternate practices (such as new models of care), the
capacity to monitor and learn from these experiments, mechanisms to support collaboration among interdependent
but autonomous actors, and strategies to connect promising local experiments to predominant institutions and
regulations in a given sector.
While it may present a somewhat idealistic view of the notion of spaces for innovation, this literature emphasizes
the importance of creating environments that are conducive to experimentation. For example, some researchers
are now looking at ways to introduce venture capital models into the development and experimentation of new care
technologies and models of care aligned with the needs of publicly funded health systems(113).
In addition, training to develop agentic capacities in network management and community mobilization is important.
The idea here is that innovation always results to some extent from a process of experimentation, accommodation
and normalization. Policies and regulations can be designed to support innovators and institutional entrepreneurs
within the health system.
Disruptive innovation and the role of distributed capacities
Innovation is always at least somewhat disruptive
(114 -117)
. Innovations that are minimally disruptive will make
their way into the health systems if there is determination to challenge some of the forces of inertia in health care(18).
Innovation demands changes to the usual ways of doing things in the daily life of an organization or a system. These
eorts have been referred to as innovation work, meaning the emotional and behavioural adjustments that potential
users have to make to put an innovation into practice. Innovation work is not an individual task – it is enacted through
distributed eorts and governance capacities(118 -120).
Adjustments in practices are needed not only at the level of individual adopters(121). The implementation of new
models of care, such as community interventions to support people with severe mental health issues, will require
governance changes in the roles of professional groups, in the relations among providers from various sectors, in
the nancing of care, in regulations and labour contracts, and in the politics that shape the delivery of care. Overall,
any signicant innovation is a source of destabilization and change in both practice settings and the broader policy
context(122). Innovation work can be facilitated by supporting distributed capacities within the health system and by
policies that promote a better alignment between the characteristics of the innovation and the system’s functioning
and regulations.
Health system reforms
Rev Bras Promoç Saúde, 31(4): 1-15, out./dez., 2018 9
Discussion and conclusion: The politics of health system redesign
In her analysis of reforms in mature health systems, one author(123) suggests that we are entering a period of
system redesign that contrasts with previous modes of reform: The politics of this redesign phase dier from both
the ‘high politics’ of welfare-state establishment and the stealth politics and short-term budgetary unilateralism of
welfare-state retrenchment. In the redesign phase, opportunities for re-allocation and re-investment are seized upon
by certain actors within the healthcare system who see the potential to benet from them. These may be ‘policy
entrepreneurs’ who want to bring a new idea to fruition. Or they may be ‘organizational entrepreneurs’ within the health
system itself, who seize upon newly available resources to innovate within the shifting context. Alliances between
these dierent types of entrepreneurs, moreover, create yet further impetus for change.
The rise of policy or organizational entrepreneurs heralds potential changes in the development of health reforms
and in the governance of health systems. The entrée en scène of these new players is not anecdotal. It may represent
a new approach to the role of governments and states in the steering of public health systems. Authors in the eld
of public administration have explored characteristics of contemporary states and governments under pressure to
‘modernize’, and in periods of austerity or pressures to contain costs. The notion of New Weberian State (NWS) has
more recently been proposed to make sense of these transformations. NWS diers from both ideas associated with
NPM and with network governance: NWS is not about radical changes to the fundamental roles of government or to
policies, but about incremental changes to governments facing new contingencies. As a model for public governance,
NWS was initially dened by two authors(124) as they attempted to compare the specicity of reforms in continental
European countries to reforms driven by more neo-liberal states (New Zealand and Australia for example).
NWS is a response to the pressures of NPM ideas and to the idea that all public administrations should implement
similar policies and use identical policy instruments to transform and adapt governments. NSW recognizes that culture
(national culture for example) and institutional context
(125)
are crucial dimensions that must be taken into account
in the process of reform. For example, the institutional landscape associated with Canadian federalism means that
it is more dicult to develop and support innovative health policies in Canada due to a strong devolution of health
responsibilities to the provinces. The NWS model is coherent with recent developments around a more decentred
approach to governance(57), where the specicities of jurisdictions are recognized as crucial in the development of
governance capacities(126). Consequently, because of the attention paid to institutional embeddedness, NSW as a
model of governance is more in line with an incremental and continuous approach to policy change than with big-
bang reforms. This model consists in a rearmation of the political power of modern states as an ingredient of social
cohesion and limited form of egalitarianism, but recognizes the need to develop more responsive public delivery
systems and, implicitly, to incorporate a more pluralistic approach to policy making.
The authors
(127)
provide a summary of the principles and approaches to governance embedded within the
NWS. The New elements of NWS consist in a shift from conformity to the internal rules of bureaucracy, toward a
more externally oriented and responsive public administration that focuses on citizens wishes and preferences,
the supplementation of representative democracy by public consultation and participation, the implementation of
results-based management and accountability, and the professionalization of bureaucrats, including the development
of experts in substantive policy areas. These principles at the heart of the NWS mean that the modernization of
governments will be somewhat synonymous to the emergence of big government well equipped to face contemporary
challenges and collective problems.
Governing and reforming health systems become possible through growing government capacity to internalize
complexity in policy making. Governments are considered the most legitimate entity to orchestrate the design of
solutions at sucient scale to address wicked problems such as achieving the Triple Aim in health care. There is
recognition that only states and governments can intervene eectively in the political economy that drives health
systems, to address predominant patterns of interests and the allocation of resources. Reforms are conducted by
public authorities. Public authorities have the responsibility to create the conditions and spaces for innovation in the
system that will promote adaptation and renewal of models of care and practices, including interventions to support
the health of the population(127).
Approaches that recall NWS with its emphasis on the role of central government in innovative policies have
been used in several provinces to overcome persistent diculties. In BC, improvements to primary care involved rst
creating a partnership between government and physicians to take on leadership of improvement eorts. Policies
to incentivize particular activities were matched by training opportunities to increase front-line capacities to reorient
practice toward priority areas, and by the creation of regional Divisions of Family Practice as forums in which physicians
could learn from each other and exchange ideas for improvement(128,129) .
Denis JL, Usher S, Preval J, Côté-Boileau E
Rev Bras Promoç Saúde, 31(4): 1-15, out./dez., 2018
10
In Saskatchewan, Lean methodology was promoted by government to improve quality and eciency, notably
in hospital settings, with funding for coaching and a requirement to report regularly on performance. In Ontario,
government preoccupation with high service users was addressed not through a formal top-down program, but
rather by encouraging voluntary partnerships among hospital and community-based providers to coordinate care for
complex patients(130). The Ontario Medical Association is supporting these eorts by oering training in establishing
better connections. Each of these instances displays a new understanding that lasting and signicant change requires
motivating actors, investing in needed supports, time to create new relationships, and tolerance for dierences in
implementation. Bottom-up experimentation with new practices appears to quite naturally lead to the emergence of
network eorts supported by a policy determination within central governments to support alternative practices. It
will be interesting to see how, over time, these initiatives contribute to large-scale and sustainable changes.
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Mailing address:
Jean-Louis Denis
Department of Management, Evaluation and Health Policy - School of Public Health, Université de Montréal
7101 Park Ave, QC H3N 1X9
Montréal - Canada
E-mail: jean-louis.denis@umontreal.ca
