One paradox of modern policy making is that the breadth and complexity of policy fields such as health care make it exceptionally difficult to consult widely on policy development and implementation; yet at the same time, the success of these policies may depend upon whether they meet the concerns and expectations of those on the receiving end. Democratic governance in policy making is thus not only a normative consideration but also a functional requirement for good performance.
When health care reform swept across Canadian provinces (largely in the 1990s), it was grounded in New Public Management models espousing the decentralization of public services to make them more responsive to the people they were designed to serve. But the regional health boards that were created across Canada were formally accountable only to the provincial ministries of health; the community health councils established in their wake (even those with a statutory base) had, at best, a spotty record of consultation with the wider public. Ontario embarked on its path to decentralization in 2004, well after other provinces, giving it the advantage of learning from these provinces’ experiences in attempting to build citizen engagement into health policy governance.
Carey Doberstein offers a thoughtful commentary on how well Ontario's fourteen Local Health Integration Networks (LHINs) have incorporated principles of democratic governance into their operation. This is not an easy task. Ontario's health system is a complex and expansive engrenage of interconnected units, while democratic principles are complicated and indeterminate concepts that shape-shift across contexts. Democratic governance can manifest itself in clear Weberian pathways of accountability; in elected delegates that may not be representative of the population; in appointed delegates that are; in transparent decision-making processes; and so on. (One of the best analyses of health care governance is perhaps the European Observatory on Health Systems and Policies’ Strengthening Health System Governance [Greer et al., Reference Greer, Wismar and Figueras2016].)
The analytical framework of Doberstein's study is sound. The author presents a three-layered model, setting out the ways in which democracy is manifest within and between each layer: the provincial government, the LHINs and the “public space.” One strength of the book is its nuance: democracy doesn't manifest itself in the same way in different contexts (which is generally a good thing, as different forms of democratic engagement can enhance each other). LHINs are accountable upward to the province in a traditional hierarchical relationship (a relationship that can be distorted if a province is too heavy-handed with its authority). At the same time, LHINs are also accountable downward to the wider population through fora such as advisory committees, citizen panels, surveys, and so on. A second strength of the book is its rich detail: there is a wealth of granularity explaining the governance structure of LHINs. No one, having read the book, could be left uncertain of how LHINs work. Particularly astute is the discussion of LHIN boards and the tension between the desire for the technical managerial experience necessary to run large complex enterprises and the quest for a constituency-based representation of “all walks of life and experience.”
Doberstein is clear that his model of “democratic arenas” is an ideal form against which to evaluate LHINs. And yet the aspirational spirit of deliberative democracy that suffused the 1990s is woven throughout this analysis. The author argues that LHINs have not been successful in “metadeliberation”: the engagement of regular people in the design of governance structures. Yet he also documents very crisply how most people prefer involvement in specific and concrete aspects of health care delivery over more abstract and technical aspects of governance design. Unlike the 1990s, where the move toward health care regionalization assumed that ordinary people would be clamouring to become involved in health policy, the current manifestation toward citizen engagement accepts that this is not a priority for most people. Most popular engagement in health care now tends toward the more localized and specific practice of “patient-oriented” health care (although this, too, is an unrepentantly fuzzy concept). The book's hopeful elaboration of metadeliberation is sweet but overly romantic. Here is where an exacting demand for transparency would be considerably more effective in securing accountability across health authorities. A skeptic might also suggest that the layers of additional administration required by deliberative democracy, including “public engagement brokers” who monitor whether input at lower levels has been adopted in higher-level decision making, might lead to even more administrative congestion in the decision-making process.
Nonetheless, given the dominance of health care within the public service domain (and given how vulnerable many people are when they access it), the question of how to evaluate responsiveness and accountability in health care governance is one we should be asking. As Ontario shifts back toward a more centralized system, incorporating the model of a single health authority in play in many other provinces, once again it has the benefit of learning from other jurisdictions’ experiences. There are advantages to amalgamation, but to the extent that decision making becomes more tightly controlled at the top, dissatisfaction can develop at the peripheries as local voices are stifled (just ask physicians in Cape Breton). Yes, health care is about providing the right services to the right people at the right time. But without the right voices being heard, this may be far more complicated than the Ontario government anticipates.
