Canada’s political leaders from provincial and federal levels meet this month to discuss health care reform. At issue is nothing less than a framework for fixing our system of health care for a generation, or so the Prime Minister promised during the recent federal election campaign.
It is time to widen the debate. Instead of focusing exclusively on familiar boundaries such as provincial or federal, private or public, the country would benefit from a more holistic discussion of whether our health care system is well suited for a digital world and what sorts of changes are in order. In fact, there is a good case to be made that the prospects for positive health care reform and e-government are closely intertwined — and should come to be viewed as such. The issue of interoperability, for example — a daunting internal challenge within governments — extends across the public sector as a whole. Whether in response to community-wide crises such as SARS, or the efficient and effective treatment of individual patients, information management and collaborative action — working better together — will make or break any effort at reform. Concerns of privacy and cyber-security remain paramount in such matters, even as the space accorded to them by politicians remains minimal.
There are also broader shifts taking place in terms of public expectations and relations between citizens and their health care providers. Physicians now face patients widely informed on medical matters from online sources (whether they are correctly informed may often be another question). Similarly, smaller and remote communities are seeking to close the urban-rural divide with e-health initiatives that make use of virtual knowledge vehicles in place of traditional care facilities.
Within individual provinces, health care systems are beginning to respond in kind. For example, Ontario’s recently announced plan to pursue local and regional health care networks is a good example of pursuing expanded inter-operability. Digital technology is the basic infrastructure on which these networks will function, ideally creating a more citizen-centric experience for the patient moving from one type of service requirement to another. Similarly, a new school of medicine, shared between two of Northern Ontario’s universities, features a specific mandate to exploit online health innovations in order to better service those furthest from the cities.
These sorts of micro-level changes, emerging across the country, may or may not be enough to ensure stability and sustainability. But the question for today is whether the First Minister’s Conference will serve as a venue to highlight and amplify such reforms, embracing their inherent complexities and interdependencies, or whether more familiar divisions and boundaries will dominate.
Much depends on political calculation and public opinion. Again, health care represents a microcosm of how e-government in the 21st century is increasingly in conflict with the 19th century origins of our federation. From one perspective, the federal government has a legitimate case to make that health care is the main priority of all Canadians: national action is therefore required. Moreover, the federal government has money to spend, and so it expects a voice in how investments are made. The provinces counter that Ottawa is the “junior partner” in health care, to invoke the characterization of the federal government by Ontario Premier Dalton McGuinty. Health care is a provincial jurisdiction, one made a lot more difficult by unilateral funding reductions by a certain Finance Minister over the previous decade and an ongoing fiscal imbalance that overly concentrates taxation federally, at the expense of program delivery provincially. The creation of e-government is and will continue to be an enormously expensive undertaking. Presuming reluctance on the part of federal leaders to voluntarily relinquish resources and power (by transferring taxation powers for example), the federal government carries enormous leverage. Some opinion polls suggest a public divided as to whether provincial or federal authorities are more capable of ensuring effective reform; other polls convey a growing desire to see governments work together.
The issue of interoperability thus becomes as political as technological. A larger federal role means collective reporting through the creation of federal/provincial co-ordination mechanisms to do so. A successful effort by the provinces to extract more resources while maintaining exclusive control can only come from better interprovincial mechanisms, interoperability of a different sort. In both cases, a spirit of collaboration is essential.
Yet, the unfortunate aspect of the present political climate is the overriding focus on what might be termed a game of competitive visibility. The televised meetings will prompt leaders to jockey for position as the true guardians of health care and good intentions. Sound bites will rule over substance. Perhaps more transparency is not always such a good thing… J
effrey Roy (roy@management.uottawa.ca) is an Associate Professor of Public Sector Management and Governance at the University of Ottawa.