Recentralization in Alberta

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Abstract

Canadian provinces are struggling to balance the tension between centralization and devolution of health system planning. Although all 10 provinces had embraced devolution to regional health authorities as a system reform measure, in May 2008, a large and wealthy province, Alberta, abandoned regional decision-making in favor of a centralized health services board that covers the entire province.

Neue Entwicklungen

The history of devolution of health planning and service delivery decision-making from central provincial governments to local authorities began in Canada in the late 1980s, first in the province of Quebec. Since then, Regional Health Authorities (RHAs) have been created in all 10 provinces (but not in the territories). The model in Ontario is somehow weaker than the model implemented in the other provinces (see (6) 2005). The goals of regionalization included improving cost containment, increasing citizen participation in decision-making,  improving system planning, increasing the emphasis on population health and wellness, and providing greater accountability (Ontario Hospital Association 2002). Many commentators have also mentioned that devolution could allow central governments to deflect criticism when unpopular decisons might be made. RHA's were responsible for planning and governance of health care including budgeting, decision making, allocation of resources and delivery of community and institutional health services. 

From the begining, the provinces struggled with the "correct" size of the RHAs and their mandates. Over time all provinces reduced the original number of RHAs (with the exception of Ontario which did not embrace devolution until 2005 and whose 14 Local Health Integration Networks are still in the early days of their mandates). In 2005, Prince Edward Island reorganized its health care system by dissolving the RHAs. Prince Edward Island is such a small province that news of the dissolution of its 4 RHAs did not cause any controversy.  

In the spring of 2008, Alberta, a large and wealthy province dissolved its nine RHA's to create a single unified health authority - The Alberta Health Services Board (AHS). The news of the change in Alberta attracted intense provincial and national scrutiny. 

The goals of Alberta's restructuring plan were reported by the government as:

• Improvement of accountability and governance
• Improved management of services,
• Increased level of health and safety across the province and,
• Standardized provincial health care so all citizens have equal access to all care and services.

In public, the Premier of the Province indicated that the public wanted a reduction in bureaucracy and improved accountability.

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral
current    previous

Regionalization in Canada may have been effective at addressing health needs in alignment with local resources and priorities but there has been little effort among any of the provinces to monitor the results of regionalization. Some have called regionalization in Canada "a good idea badly done" (Fyke in Health Edition, 2008a). 

In Alberta, where it may have failed was in its ability to ensure all citizens had accessibility to needed services independent of the jurisdiction they lived in. The politics of health care in a publicly funded system requires that either politicans are removed from changing the "rules" for the delivery system (through the creation of an arms-length corporation for example) or that politicans are better educated about how and why RHAs operate. To accomplich the latter, performance measurement needs to be a stronger component of the accountability system. 

It is uncertain whether or not Alberta will be able to reach its health policy goals using the new structure. The Ministry needs to adopt a transparent way of doing business so that all actors can remain informed and the new Board is seen to be accountable for its performance.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Initiators of idea/main actors

• Regierung

• Leistungserbringer

• Wissenschaft

• Politische Parteien

Stakeholder positions

Health care costs and service delivery issues are a feature in any provincial election in Canada. Alberta had a change in leadership with a new Premier and a new Minister of Health. The Minister of Health and Wellness is responsible for the restructuring of Alberta's health care system. The (new) Minister stated that reorganization of the health system was rooted in porposals contained in reports commissisoned by the government since 2001. These reports, the Mazankowski Report and the second report which is known as The "Third Way" package of reforms announced by former premier Ralph Klein, called for either a review of services that should be covered by the public system or outright private provision of some health services. The new Minister of Health announced that there would not be a parrallel private health care system in Alberta but it is not clear yet how the new Health Services Board will be expected to address coverage issues.

There have been various statements about the mandate of the new Board. The government also announced that a key goal is to improve equitable access to care across the province. The Premier stated that the mandate of the new Board was to reduce administrative costs and increase front-line care. The Minister of Health and Wellness announced that he had no plans to start cutting healthcare spending but did not provide details about how the responsibilites of the new Board would be fulfilled. 

The opposition parties do not support the move to centralization because the government has presented no evidence that feasibility or efficiency have been considered in creating a province-wide board. 

RHA CEOs were publicly supportive of the change. Most of them were expected to get positions in the new system.

Two advocacy groups, Friends of Medicare and United Nurses of Alberta are opposed to the restructuring of Alberta's health care system because the Minister of Health has not provided details of how the new Board would operate. The Ministry's silence about implementation created uncertainty among health provider organizations, staff and some consumers. 

In August the Alberta Medical Association, which supports the elimination of the RHAs, called on the new Board to address the issue of pandemic planning. The creation of a single health services board will allow a province-wide approach to such issues as pandemic planning.

Actors and positions

Regierung
Minister of Health	sehr unterstützend		stark dagegen
Premier	sehr unterstützend		stark dagegen
Leistungserbringer
Some Alberta RHA CEOs	sehr unterstützend		stark dagegen
Alberta Medical Association	sehr unterstützend		stark dagegen
Rural Hospitals	sehr unterstützend		stark dagegen
Wissenschaft
Some provincial health economists	sehr unterstützend		stark dagegen
Some national health policy experts	sehr unterstützend		stark dagegen
Politische Parteien
Opposition (Liberal Party)	sehr unterstützend		stark dagegen
Party in Power (Conservative Party)	sehr unterstützend		stark dagegen
current    previous

Influences in policy making and legislation

Passage of legislation to eliminate the former 9 RHAs and create the Alberta Health Services Board was supported by the government.

Legislative outcome

Enactment

Actors and influence

Regierung
Minister of Health	sehr groß		kein
Premier	sehr groß		kein
Leistungserbringer
Some Alberta RHA CEOs	sehr groß		kein
Alberta Medical Association	sehr groß		kein
Rural Hospitals	sehr groß		kein
Wissenschaft
Some provincial health economists	sehr groß		kein
Some national health policy experts	sehr groß		kein
Politische Parteien
Opposition (Liberal Party)	sehr groß		kein
Party in Power (Conservative Party)	sehr groß		kein
current    previous

Positions and Influences at a glance

Adoption and implementation

The members of the Alberta Health Services Board have been appointed and the organizational structure of the Board have been announced.

Monitoring and evaluation

There has been no formal evaluation of regionalization in Alberta.

Expected outcome

Some Canadian health policy analysts question regionalization as an effective solution to the ills of the health delivery system; the firmest conclusion that some have reached is that in Canada only a limited form of regionalization has been reached (Lewis and Kouri, 2004). The continuing realignment of boundaries in the provinces and the recent elimination of regional bodies in Alberta indicate that implementing regionalization has been unstable In Canada. Lewis and Kouri (2004) identifed a number of issues with Canadian models of regionalization:

• Performance measures need to be developed to assist the RHAs to better align resources and needs in local communities
• Physicians need to be more fully included in the mandates of regional health authorities in order to reduce fragmentation of care
• Drug budgets should be more fully integrated into the RHA mandates
• There need to be changes in organizational cultures to adopt a population health approach
• There need to be improvements in investments in evidence-based research and in information technologies
• Governance structures need to be improved.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch
current    previous

References

Sources of Information

• www.albertahealthservices.ca  
• Alberta Medical Association (2008). "Alberta doctors call on Alberta Health Services Board for action and communication about pandemic planning."  News Release. September 19.
• CBC news (2008). "Alberta unveils prescription for health care." April 16.
• CBC news (2008). "Mixed Reaction to merging Alberta health regions." May 15.
• Health Edition (2008a). "Shortcomings of regional health services criticized." 12:21: 1.
• Health Edition (2008b). "Regional health CEOs Dismissed in Alberta." 12:27: 1.
• Lewis, S & D. Kouri (2004). "Regionalization: Making Sense of the Canadian Experience." Healthcare Papers 5(1): 12-31.
• Ontario Hospital Association (2002). Regional Health Authorities in Canada: Lessons for Ontario. A Discussion Paper. www.oha.com
• Picard, A. (2008). "Centralization: A step back for Alberta health care?" The Globe and Mail P L5.  May 22.

Reform formerly reported in

Ontario's Local Health Integration Networks Process Stages: Umsetzung

Author/s and/or contributors to this survey

Margaret MacAdam and Stephanie Mackenzie

Empfohlene Zitierweise für diesen Online-Artikel:

Margaret MacAdam and Stephanie Mackenzie. "Recentralization in Alberta". Health Policy Monitor, October 2008. Available at http://www.hpm.org/survey/ca/b12/4