National Library Bibliotheque nationale 1*1 of Canada du Canada Acquisitions and Acquisitions et Bibliographie Services semices bibliographiques 395 Weilic.qtm Street 395,cus Wawt0f-l Onawa ON K1A -ON KlAW Canada Cariada The author has granted a non- L'auteur a accordé une licence non exclusive licence aiiowing the exclusive permettant a la National Library of Canada to Bibliothèque nationale du Cana& de reproduce, loan, distribute or seii reproduire, prêter, distribuer ou copies of this thesis in microform, vendre des copies de cette thèse sous paper or electronic formats. la forme de microfiche/film, de reproduction sur papier ou sur format électronique. The author retains ownenhip of the L'auteur conserve la propriété du copyright in this thesis. Neither the droit d'auteur qui protège cette thèse. thesis nor substantial extracts ikom it Ni la thèse ni des extraits substantiels may be printed or othenvise de celle-ci ne doivent être imprimés reproduced without the author's ou autrement reproduits sans son permission. autorisation. Abstract The case study examines impacts on the exercise of power and the allocation of resources in health care delivery in British Columbia stemming fiom provincial policies of regionalization and devolution. The study examines the policy implementation process fiom 1993 to 1999, with the emphasis falling on the policy controversy provoked by the New Directions reforrn (1993 to 1996). The study also contributes to theory development regarding the policy implementation process by expounding and appiying an approach to policy-as-ideology. Another subsidiary purpose is to contribute to theory regarding the power and accountability of health care providers and lay members of health services' govemance structures. The study demonstrates the persistence of structural power relations within the health care sector. It concludes that the health refonn initiative failed to impose controls over health care professionals and providers, failed to improve accountability of programmes to the public, failed to affect a reallocation of resources in the health sector, and failed to SMthe policy perspective fiom the delivery of health care services to a comrnunity health perspective. The reorganization that was achieved through the refom did, however, strengthen administrative arrangements and improve technical efficiency. Table of Contene Preface ................................................................................................................. .... ...................................... vi ... Acknowledgements ................................................................................................................................... xiii 1 . 1 PURPOSE............................................................................................................................................... 1 1.2 DESIGN.................................................................................................................................................. 3 1.3 B.ACKGROUND,m~ ASSüMPTIONS, AND THEORETICALFUMEWORK .................... .. ....................... 3 1.4 THEORETICALSIGNIFICANCE .............................................................................................................. 11 1.4. 1 Primary Case .................. .. ....................................................................................................... II 1.4.2 Em bedded Case ........................... .. ........................................................................................ 12 1.5 THECASE STUDY APPROACH .............................................................................................................. 14 2.1 BACKGROUNDTO THE POLICY COM~~LTNITYAPPRO:\CH ..................................................................... 19 2.2 POLICYCOM% ~WN~TIE~ AND N~ORKS .............................................................................................. 21 2.3 MAJOR~SSUMP'ITONS AND LIMITATIONSIN THE POLICYCOMMWNITY LITERATURE .......................... 25 2.4 NEO-ISSTITUTIONALISM..................................................................................................................... 27 2.5 IDEASAND POLICY CHANGE...................................................... ........................................................ 31 2.6 EST~LISHIKGTHE CONTEYTOF SOCCALACTION ............................................................................... 35 2.7 POWERAND INTERESTS ....................................................................................................................... 37 2.8 STRUCTURAL INTERESTS, N~VORKSAND POLlCY COMMUNITIES ................................................. -40 2.9 POLICYAS IDEOLOGY.......................................................................................................................... 42 2.9.1 The Brïrish Columbia Healrh Policy Con~munity....................................................................... 50 2.9.3 Merhods ...................................................................................................................................... 58 3.1 .L\ CIENDA SETTING:INTERESTS. INSTITUTIONSAND POLITICS............................................................. 60 3.2 FRAMES,INSTIT~T~ONS AND PATUDEPMDENCY: MEDICAL SERVICES INSUMSCE ........................ .. 66 3.3 FR~MESAND INSTITUTIONS: REGIONALIZA~ON............................................................................. 74 3.4 ACTION FUMING: POWERAND DEVOLUTION.................................................................................... 81 3.5 POLICY FORVULAT~ON:REPORT OF THE B.C. ROYALCOMMISSION ON HEALTHCA= AND COSTS-85 CHAPTER W:NEW DIRECTlONS .......................................................................................................-92 4.1 NEIVDIRECTIONS:POLICY OVERVIEW ............................................................................................ SSSSS92 4.2 POLICYELEMENTS .............................................................................................................................. 94 4.2.1 Mirtirterial Statement ................................................................................................................. 94 4.2.2 A Guide for Developing CHCs and RHBs .................................................................................. 98 4.2.3 Our Undersranding of fiealth ...............*..... ............... ... ................. 10 1 4.7.4 The Healrh Authoriries Act ..................................................................................................... 102 4.3 POLICYIMPLEMENTATION ................................................................................................................ 103 4- 3.1 Cornmuniries Putting New Direcrions inro Action ................................................................. 103 4.3.2 Fonning Community Healrh Councils and Regional Healrh Boards .................... ... ........,.. 104 4-3.3 Planning for Cote Services and Srandardr ............................................................................... 105 4.3.4 Regional Health Boundaries; Community Health Council Boundaries .................................. -106 4.3.5 Berfer Provincial Health ........................................................................................................... l 07 4.3.6 Torvards a New Policy Community ........................................................................................... 108 4.3.7 The Depury Minister 3 Advisory Cornmirtee ......................................................................... 109 CHAPTER V: THE ESTABLISHED POLICY FR4MES ........................................ 12 5.1 THEIDEOLOGY OF HEALTH CARE:THE LMEDICAL PROFESSION'S FRAME. .................................... 112 5.2 THEUXION PERSPECTCVE: ORGANIZEDLABOUR'S FUME ............................................................... 119 CHAPTER VI: TO WARDS BETTER TEAMWORAE.......... ......................... ...-.................................... 123 6.1 THERETREAT FROM NEW DIRE~ONS.............................................................................................. 123 6.1.1 Executive Directors. Transition Teams and Interim CEOs............... ... .................................... 128 6.1.2 The? IChiring Lbt Cris& ............................................................................................................. 132 6.1.3 Regionalirarion of Terriary Care Services............................................................................. -133 6.1.4 Roles and Responribiliries of CHCs and RHBs ................................................................... 134 6.2 EVALUATIONOF NEW DIREC;TIONS.................................................................................................... 135 6.2.1 Ministerial Review and the Assessmenr Team .......................................................... .. .......... 135 6.2.2 Berrer Teamwork...................................................................~................................. .. ...........-137 6.3 IMPLICATIONSFOR LABOUR RELATIONS........................................................................................... 140 6.3 LMPLICATIONS FOR CON-[Z\IPOWYHMLTH CAREPOLITICS LN B.C. ............................................. 144 6.4.1 CIoser to Home: Services tu Rural Brinkh Columbians .................................................... 145 6.4.2 The Fee Dispute .................................. .... ...........................................................................