Health Care in Federal Systems

How do multilevel health care systems evolve? Do they develop in a similar manner, or are their respective paths of evolution more sui generis? The aim of this article is to compare the way in which Canada and the European Union have attempted to coordinate health policy between their component multilevel jurisdictions over time. This article argues that the EU—despite its limited authority over health care—has been better able than Canada to develop a greater capacity for addressing health policy at a supranational level, notwithstanding Canada’s greater federal involvement in financing health care. While the experience of the EU supports the theoretical premises of neofunctionalism (that a certain level of integration will induce even greater integration in other areas, especially in response to crisis), the experience of Canadian health care federalism does not fit that theoretical paradigm. This suggests a limited applicability for neofunctionalist theory across multilevel systems more widely

Getting Representation Right for Women in Development: Accountability, Consent, and the Articulation of Women's Interests

Summary To what extent does the recent emphasis upon accountability by development institutions augur well for women? This article firstly describes how accountability is grounded upon the concept of consent as the principal prerequisite of legitimate authority; secondly notes how consent has historically played an ambivalent role for women; and finally argues that placing consent within a ‘context of choice’ which recognizes cultural identity threatens to negate the value of consent for women in development. RESUME La représentation fidèle des femmes dans le développement: la responsabilité financière, l'assentiment, et l'articulation des intérêts des femmes L'emphase récente sur la responsabilité financière exigée par les institutions de développement estelle de bonne augure pour les femmes, et jusqu'à quel point? Dans un premier temps, cet article examine comment la responsabilité financière se fonde sur un concept où l'assentiment est l'exigence préalable et primordiale de l'autorité légitime; ensuite l'auteur observe comment, dans l'histoire, l'assentiment a joué un rôle ambivalent du point des femmes; et en dernier lieu, elle affirme que le fait de cerner l'assentiment dans un ‘contexte de choix’ qui reconnaît l'identité culturelle, risque de réduire à zéro la valeur de l'assentiment des femmes au développement. RESUMEN Representación acertada de la mujer en el desarrollo; responsabilidad, consentimiento, y la articulación de los intereses de la mujer ¿Hasta qué punto augura bien para la mujer el énfasis reciente en la responsabilidad a cargo de las instituciones de desarrollo? Este artículo describe primeramente cómo la responsabilidad se basa en el concepto de consentimiento como requerimiento principal para la autoridad legítima; en segundo lugar, se destaca en qué forma el consentimiento ha jugado históricamente un papel ambivalente para la mujer, y finalmente se argumenta qué la ubicación de consentimiento dentro de un ‘contexto de libre selección’ que reconoce la identidad cultural, amenaza con negar el valor de aquél para la mujer en el proceso de desarrollo

Transparency Too Little, Too Late? Why and How Health Canada Should Make Clinical Data and Regulatory Decision-Making Open to Scrutiny in the Face of COVID-19

Hard-won gains in the transparency of therapeutic product data in recent years1 have occurred alongside growing reliance by regulators upon expedited review processes.2 The concurrence of these two trends raises fundamental questions for the future of pharmaceutical regulation about whether the institutionalization of transparency will foster improved oversight of drugs, biologics, vaccines, and other interventions, or else, provide cover for a relaxing of regulatory standards of safety, effectiveness, and quality.3 The urgency of the COVID-19 pandemic, however, has brought this tension into immediate and sharp relief. During the course of the global health crisis, regulatory bodies have markedly expanded the number and use of expedited review processes for COVID-19 therapies, and at the same time, the proliferation of misinformation about any potential SARS-CoV-2 intervention4 reveals the limitations of recently implemented transparency measures

Amalgamating Provincial Health Authorities: Assessing the Experience of Nova Scotia

Reflecting the shift away from regionalized health governance in Canada's provinces, the Nova Scotia government consolidated its nine Distinct Health Authorities into the single Nova Scotia Health Authority as of 1 April 2015. Regionalized health administration had originally been expected to produce economic efficiencies but, after two decades, a fragmented system of health governance was increasingly perceived as inflexible, uneven, and expensive. A more centralized system was presented as a means of reducing administrative costs, promoting scale economies, allowing greater flexibility, and facilitating standardization, which would in turn lead to significant savings. Five years on, however, the expected cost savings have not materialized. While there has been more success in standardization of services, not all attempts at standardization have led to greater efficiency. Evidence for greater flexibility is mixed. Problems with amalgamating health authorities include opportunity costs incurred by thoroughgoing reform, ambiguous and diminished accountability, administrative bottlenecks, decreased responsiveness, and poor working relationships with health care professionals leading to issues of access to health care services. Suivant le mouvement de dé-régionalisation amorcé dans d'autres provinces canadiennes, le gouvernement de Nouvelle Écosse a consolidé ses neuf Autorités de Santé Distinctes en une seule autorité sanitaire le 1er avril 2015. Initialement, l'attente était que la régionalisation de l'administration sanitaire apporterait des gains d'efficience, mais, après deux décennies, les systèmes fragmentés de gouvernance de la santé ont été perçus comme rigides, injustes et coûteux. Recentraliser le système a été présenté comme un moyen de réduire les coûts administratifs, de promouvoir des économies d'échelle, de permettre une plus grande flexibilité, et de faciliter la standardisation pour générer des économies substantielles. Après cinq années, cependant, les économies attendues ne se sont pas matérialisées. Même si la standardisation des services a été plus réussie, il n'en reste pas moins que la standardisation n'a pas toujours amélioré l'efficience. L'évidence empirique sur l'amélioration de la flexibilité est tiède. Parmi les problèmes liés à la consolidation des autorités sanitaires, on peut citer des coûts d'opportunité liés à la mise en place de la réforme, une moindre transparence comptable, des goulots d'étranglement administratifs, une moindre attention aux attentes des usagers, et des relations détériorées avec les professionels de santé amenant des problèmes d'accès aux soins

Reforming the Regulation of Therapeutic Products in Canada: The Protecting of Canadians from Unsafe Drugs Act (Vanessa’s Law)

Enacted November 2014, Vanessa’s Law amends the Food and Drugs Act to give Health Canada greater powers to compel the disclosure of information, recall drugs and devices, impose fines and injunctions, and collect post-market safety information. The Act amends seriously outdated legislation that had been in place since 1954. While the explicit goals of the Act are to improve patient safety and provide transparency, it also establishes a regulatory framework that facilitates investment in the burgeoning field of biotechnology. While regulatory reform was already on the public agenda, public awareness of litigation against large pharmaceutical firms combined with the championing of the legislation by Conservative MP Terence Young, whose daughter Vanessa died from an adverse drug reaction, pushed the legislation through to implementation. Many key aspects of the Act depend upon the precise nature of supporting regulations that are still to be implemented. Despite the new powers conferred by the legislation on the Minister of Health, there is some concern that these discretionary powers may not be exercised, and that Health Canada may not have sufficient resources to take advantage of these new powers. Given experience to date since enactment, the new legislation, designed to provide greater transparency vis-à-vis therapeutic products, may actually have a chilling effect on independent scrutiny

Amalgamating Provincial Health Authorities

Reflecting the shift away from regionalized health governance in Canada's provinces, the Nova Scotia government consolidated its nine Distinct Health Authorities into the single Nova Scotia Health Authority as of 1 April 2015. Regionalized health administration had originally been expected to produce economic efficiencies but, after two decades, a fragmented system of health governance was increasingly perceived as inflexible, uneven, and expensive. A more centralized system was presented as a means of reducing administrative costs, promoting scale economies, allowing greater flexibility, and facilitating standardization, which would in turn lead to significant savings. Five years on, however, the expected cost savings have not materialized. While there has been more success in standardization of services, not all attempts at standardization have led to greater efficiency. Evidence for greater flexibility is mixed. Problems with amalgamating health authorities include opportunity costs incurred by thoroughgoing reform, ambiguous and diminished accountability, administrative bottlenecks, decreased responsiveness, and poor working relationships with health care professionals leading to issues of access to health care services. Suivant le mouvement de dé-régionalisation amorcé dans d'autres provinces canadiennes, le gouvernement de Nouvelle Écosse a consolidé ses neuf Autorités de Santé Distinctes en une seule autorité sanitaire le 1er avril 2015. Initialement, l'attente était que la régionalisation de l'administration sanitaire apporterait des gains d'efficience, mais, après deux décennies, les systèmes fragmentés de gouvernance de la santé ont été perçus comme rigides, injustes et coûteux. Recentraliser le système a été présenté comme un moyen de réduire les coûts administratifs, de promouvoir des économies d'échelle, de permettre une plus grande flexibilité, et de faciliter la standardisation pour générer des économies substantielles. Après cinq années, cependant, les économies attendues ne se sont pas matérialisées. Même si la standardisation des services a été plus réussie, il n'en reste pas moins que la standardisation n'a pas toujours amélioré l'efficience. L'évidence empirique sur l'amélioration de la flexibilité est tiède. Parmi les problèmes liés à la consolidation des autorités sanitaires, on peut citer des coûts d'opportunité liés à la mise en place de la réforme, une moindre transparence comptable, des goulots d'étranglement administratifs, une moindre attention aux attentes des usagers, et des relations détériorées avec les professionels de santé amenant des problèmes d'accès aux soins

Reforming the Regulation of Therapeutic Products in Canada: The Protecting of Canadians from Unsafe Drugs Act (Vanessa’s Law)

Enacted November 2014, Vanessa’s Law amends the Food and Drugs Act to give Health Canada greater powers to compel the disclosure of information, recall drugs and devices, impose fines and injunctions, and collect post-market safety information. The Act amends seriously outdated legislation that had been in place since 1954. While the explicit goals of the Act are to improve patient safety and provide transparency, it also establishes a regulatory framework that facilitates investment in the burgeoning field of biotechnology. While regulatory reform was already on the public agenda, public awareness of litigation against large pharmaceutical firms combined with the championing of the legislation by Conservative MP Terence Young, whose daughter Vanessa died from an adverse drug reaction, pushed the legislation through to implementation. Many key aspects of the Act depend upon the precise nature of supporting regulations that are still to be implemented. Despite the new powers conferred by the legislation on the Minister of Health, there is some concern that these discretionary powers may not be exercised, and that Health Canada may not have sufficient resources to take advantage of these new powers. Given experience to date since enactment, the new legislation, designed to provide greater transparency vis-à-vis therapeutic products, may actually have a chilling effect on independent scrutiny

Health Inequity and Institutional Ethnography: Mapping the Problem of Policy Change

Health equity (HE) is a central concern across multiple disciplines and sectors, including nursing. However, the proliferation of the term has not resulted in corresponding policymaking that leads to a clear reduction of health inequities. The goal of this paper is to use institutional ethnographic methods to map the social organization of HE policy discourses in Canada, a process that serves to reproduce existing relations of power that stymie substantive change in policy aimed at reducing health inequity. In nursing, institutional ethnography (IE) is described as a method of inquiry for taking sides in order to expose socially organized practices of power. Starting from the standpoints of HE policy advocates we explain the methods of IE, focusing on a stepwise description of theoretical and practical applications in the area of policymaking. Results are discussed in the context of three thematic areas: 1) bounding HE talk within biomedical imperialism, 2) situating racialization and marginalization as a subaltern space in HE discourses, and 3) activating HE texts as ruling relations. We conclude with key points about our insights into the methodological and theoretical potential of critical policy research using IE to analyze the social organization of power in HE policy narratives. This paper contributes to critical nursing discourse in the area of HE, demonstrating how IE can be applied to disrupt socially organized neoliberal and colonialist narratives that recycle and redeploy oppressive policymaking practices within and beyond nursing