DOMINANT, CONTESTED and ABSENT THEMES a Thesis

DISCOURSES AND PRACTICES OF HEALTH SYSTEM REGIONALIZATION IN SASKATCHEWAN: DOMINANT, CONTESTED AND ABSENT THEMES A Thesis Submitted to the College of Graduate Studies and Research In Partial Fulfillment of the Requirements For the Degree Doctor of Philosophy In Interdisciplinary Studies University of Saskatchewan Saskatoon By Kelly Chessie © Kelly Chessie, December 2011. All rights reserved. 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The author retains copyright L'auteur conserve la propriété du droit d'auteur ownership and moral rights in this et des droits moraux qui protege cette thèse. Ni thesis. Neither the thesis nor la thèse ni des extraits substantiels de celle-ci substantial extracts from it may be ne doivent être imprimés ou autrement printed or otherwise reproduced reproduits sans son autorisation. without the author's permission. In compliance with the Canadian Conformément à la loi canadienne sur la Privacy Act some supporting forms protection de la vie privée, quelques may have been removed from this formulaires secondaires ont été enlevés de thesis. cette thèse. While these forms may be included Bien que ces formulaires aient inclus dans in the document page count, their la pagination, il n'y aura aucun contenu removal does not represent any loss manquant. of content from the thesis. PERMISSION TO USE In presenting this thesis in partial fulfillment of the requirements for a postgraduate degree from the University of Saskatchewan, I agree that the libraries of this University may make it freely available for inspection. I further agree that permission for copying of this thesis in any manner, in whole or in part, for scholarly purposes may be granted by the professor or professors who supervised my thesis work or, in their absence, by the Head of the Department or the Dean of the College in which my thesis work was done. It is understood that any copying or publication or use of this thesis or parts thereof for financial gain shall not be allowed without my written permission. It is also understood that due recognition shall be given to me and to the University of Saskatchewan in any use made of any material in my thesis. Requests for permission to copy or make other use of materials in this thesis in whole or part should be addressed to: Head of Interdisciplinary Studies University of Saskatchewan Saskatoon, Saskatchewan S7N 5A5 or Dean, College of Graduate Studies and Research University of Saskatchewan Saskatoon, Saskatchewan S7N 5A5 i ABSTRACT Policies of health system regionalization with agendas of increased public participation were significant components of Saskatchewan health reforms of the 1990s. Regionalization entailed both devolving and centralizing powers from provincial ministries and local facility boards to newly created regional boards comprised of local community members who would now be in charge of planning and delivering local health services. An under-considered area in policy studies is the interpretation and agency of central actors charged with taking government announcements and public policy amendments and enacting these into day-to-day practices. This dissertation explores this interpretive space. Based on interviews with 11 Health Authority Board Chairs, 8 health region CEOs, 8 Ministry of Health officials, and 5 members of Advisory Networks, this research examines how these actors framed and practiced ―regionalization‖ and ―public participation‖ policies. Drawing on a discourse analysis utilizing NVIVO software, my analysis revealed that the central actors framed their interpretations and practices of regionalization within technocratic logics: regionalization and public participation policies were interpreted and constructed as routes to efficient and effective services. Although population health logics framing the policies in terms of their empowerment potentials were called on early in the reforms, these logics no longer appear in the discourse and practices. Democratic traces and concerns of local representation and accountabilities persist. While largely accommodated and hybridized within technocratic framings, sites of democratic-technocratic contestation remain. In keeping with broader transformations, publics are increasingly called upon to participate not as citizens but as responsible patients and families, with individualizing patient, client, and consumer positions being prioritized over collective positions of communities and populations. Technical accuracy appears to takes precedence over public accountability and engagement. Experts make decisions, with input provided by reflexive publics, and the ultimate goal is an efficient system. ii ACKNOWLEDGEMENTS This project could not have happened without the generous support of many and I begin by recognizing the 32 individuals who sat down to talk with me about their experiences with, and understandings of, public participation and health system regionalization. I appreciate your time and interest. Thank you. I would like to acknowledge the support of my PhD supervisor, Dr. Lesley Biggs. Your generosity with your time, your knowledge, and your patience were invaluable to my successful completion and my academic growth. Thank you. I acknowledge my committee members, Dr. Tom McIntosh, Steven Lewis, Dr. Kurt Wetzel, and Dr. Murray Knuttila. Your questions and our conversations were fruitful, and of course, by times, frustrating as hell and humbling. I am a stronger scholar for it. Thank you. I would like to recognize the time and interest of my external examiner, Dr. Pat Armstrong. It was an honour to have you consider my work. I acknowledge SSHRC for Canada Graduate Scholarship 767-2006-2529 and the Saskatchewan Population Health Evaluation and Research Unit for a CPHR Fellowship. Last, but never least, indeed most, I extend gratitude to Zane Wilcox. You walked this one with me, and were always so generous with your encouragement and belief (not to mention the use of your truck for all my travel). My precious after-work hours and weekend time is once again ours. Now let‘s go have some fun! iii To Glenn Andre, Habermas-tutor and much missed friend. Every day things disappear iv TABLE OF CONTENTS PERMISSION TO USE ....................................................................................................... i ABSTRACT ........................................................................................................................ ii ACKNOWLEDGEMENTS ............................................................................................... iii TABLE OF CONTENTS .................................................................................................... v LIST OF TABLES ........................................................................................................... viii LIST OF ABBREVIATIONS ............................................................................................ ix CHAPTER 1: INTRODUCTION ....................................................................................... 1 1.1 Overview ................................................................................................................... 1 1.2 Regionalization in Canada: Macro-Level Contexts .................................................. 5 1.3 Regionalization in Saskatchewan: Meso-Level Contexts ......................................... 8 1.4 The Present Study ................................................................................................... 14 1.5 Overview of the Dissertation .................................................................................. 16 CHAPTER 2: LITERATURES AND INTERPRETIVE LENSES .................................. 21 2.1 Overview ................................................................................................................. 21 2.2 The Regionalization Literature ............................................................................... 23 2.2.1 Introduction ...................................................................................................... 23 2.2.2 Canadian Studies of Regionalization ............................................................... 24 2.2.3 Summary .......................................................................................................... 29 2.3 The Public Participation Literature ......................................................................... 31 2.3.1 Introduction ...................................................................................................... 31 2.3.2

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