Organizing health care is sort of like playing the game of Risk. The goal of the game is simple: to eliminate other players and take over the world. Victory approaches as you expand your own territory and knock your opponents off the board. In order to be successful, you must have strategy. Should you start in Australia, or South America? Should you ally with other players, or work independently? Should you scatter armies abroad, or concentrate in one area and expand? Regardless of these decisions, your strategy is not your solution, but it determines how you play the game.
Likewise, a province’s decision to centralize or decentralize health services should be seen as a strategy, not a solution.
Both centralization and decentralization have been ‘fads’ at one time or another. Revolutionary health documents like the Ottawa Charter for Health Promotion and Lalonde report (formally titled A new perspective on the health of Canadians) revealed that a hospital-based health care system was unsustainable. They redefined health as a state of wellbeing and emphasized the various factors that affect health, such as income, physical environment and social supports. Therefore, throughout the 1990s, small community hospitals were amalgamated. Provincial heroes rose up across the country to create strategy plans that advocated for regionalization. This led to the formation of regional health districts.
Regionalization is when provincial power authority is dispersed. It is a strategy that gives ownership to local communities and promotes leadership and stewardship. It favours rural communities, especially women, by promoting the continuity of key services like public health and obstetric and emergency care. It allows locals, the people who know their community the best, to decide where services are located, what is offered and what resources they will use.
However, these regions were put in place with little direction or mentorship. Provincial legislature, such as the Regional Health Acts, provided guidelines for finances, accountability and responsibility. But like any board game, the best way to learn is by someone teaching you. Someone telling you when do roll the die, pick up a card and encouraging you when you make mistakes. Sure, you can read the instructions, but this is time consuming. You have to keep checking the multi-folded, 6pt font manual to make sure you are doing things ‘by the book’. The health of Canadians continued to deteriorate even with regionalization. Therefore, the pendulum swung to a different strategy, centralization.
Centralization occurs when decision-making power is concentrated in one place. It can quickly become an ‘insert-city-here’ health system. Centralization can be convenient and efficient. Think of it like a department store that offers groceries, clothing, pet toys and pharmaceuticals, all in one place. But, a centralized system is only convenient to the people who can access it. What about that community up north? What about the elderly folks living outside of town? Centralization has the same principles as rotational inertia. As a mass moves further from its center it becomes more difficult to move. Picture a figure skater who ends their routine by spinning on the ice. They spin more quickly as their arms and legs move inward towards their body. The same applies to decisions about health care. As the person who makes all the decisions is farther away from the community, so too are the context of their decisions.
So what makes centralization and decentralization so confusing? Well, there is no single right answer. Let’s go back to our board game analogy. Is there one set strategy that guarantees you a win every time? Of course not. This is because each game varies according to game players, numbers and chance. It’s important for each province to look at all the factors that go into their strategy: road structure, urban populations, and retention of health workers, to name a few. We want a quick fix solution that promises to take our troubles away. But one simply doesn’t exist.
Regionalization is often treated as a solution. When it doesn’t produce good results, like cost savings and community engagement, provincial governments quickly move to centralization. With such strict rules, little guidance and no room for creativity, I wonder, has regionalization been given a real chance?
Rural Newfoundland has had some hard hits over the last few decades. Our population is aging, our cod fish industry is diminished, and illnesses are more chronic than acute. It’s time for rural communities to be place makers instead of case makers. Rather than crying out for help in hopes that someone will hear about their troubles, it’s time for rural communities to find their place. Rural communities are important. They provide natural resources, historic relevance and a unique way of living. Regionalization is a strategy that promotes community-derived solutions. It will require civic engagement and a shift in culture but has the potential to revitalize rural communities in the long term.
Laura Kennedy / St. John’s