Legislating collaborative self-regulation in Canada: A comparative policy analysis.

To encourage interprofessional collaboration and to improve the regulation of healthcare providers, Ontario and Nova Scotia, Canada, have each adopted legislation calling for collaboration among the regulators of their self-regulating health professions. Ontario's legislation is "top down": it came from government and stresses the obligation of regulators to collaborate. Nova Scotia's legislation is "bottom up": it was proposed and developed by regulators and emphasizes voluntary regulatory collaboration. This article considers the theoretical strengths and weaknesses of both models. It argues that Nova Scotia's approach may be stronger because of its relative consistency with core strengths of self-regulation and interprofessionalism and its grounding in soft law and a governance approach to collaborative self-regulation and to healthcare policy more broadly.

Strategies and indicators to integrate health equity in health service and delivery systems in high-income countries: a scoping review.

OBJECTIVE: The objective of this review was to describe how health service and delivery systems in high-income countries define and operationalize health equity. A secondary objective was to identify implementation strategies and indicators being used to integrate and measure health equity. INTRODUCTION: To improve the health of populations, a population health and health equity approach is needed. To date, most work on health equity integration has focused on reducing health inequities within public health, health care delivery, or providers within a health system, but less is known about integration across the health service and delivery system. INCLUSION CRITERIA: This review included academic and gray literature sources that described the definitions, frameworks, level of integration, strategies, and indicators that health service and delivery systems in high-income countries have used to describe, integrate, and/or measure health equity. Sources were excluded if they were not available in English (or a translation was not available), were published before 1986, focused on strategies that were not implemented, did not provide health equity indicators, or featured strategies that were implemented outside the health service or delivery systems (eg, community-based strategies). METHODS: This review was conducted in accordance with the JBI methodology for scoping reviews. Titles and abstracts were screened for eligibility followed by a full-text review to determine inclusion. The information extracted from the included studies consisted of study design and key findings, such as health equity definitions, strategies, frameworks, level of integration, and indicators. Most data were quantitatively tabulated and presented according to 5 secondary review questions. Some findings (eg, definitions and indicators) were summarized using qualitative methods. Most findings were visually presented in charts and diagrams or presented in tabular format. RESULTS: Following review of 16,297 titles and abstracts and 824 full-text sources, we included 122 sources (108 scholarly and 14 gray literature) in this scoping review. We found that health equity was inconsistently defined and operationalized. Only 17 sources included definitions of health equity, and we found that both indicators and strategies lacked adequate descriptions. The use of health equity frameworks was limited and, where present, there was little consistency or agreement in their use. We found that strategies were often specific to programs, services, or clinics, rather than broadly applied across health service and delivery systems. CONCLUSIONS: Our findings suggest that strategies to advance health equity work are siloed within health service and delivery systems, and are not currently being implemented system-wide (ie, across all health settings). Healthy equity definitions and frameworks are varied in the included sources, and indicators for health equity are variable and inconsistently measured. Health equity integration needs to be prioritized within and across health service and delivery systems. There is also a need for system-wide strategies to promote health equity, alongside robust accountability mechanisms for measuring health equity. This is necessary to ensure that an integrated, whole-system approach can be consistently applied in health service and delivery systems internationally. REVIEW REGISTRATION: DalSpace dalspace.library.dal.ca/handle/10222/80835.

Strategies and indicators to address health equity in health service and delivery systems: a scoping review protocol.

OBJECTIVE: The purpose of this review is to describe how health service and delivery systems support health equity, and to identify strategies and indicators being used to measure health equity. INTRODUCTION: It is widely acknowledged that a population health and equity approach is needed to improve the overall health of the population. The health service and delivery system plays an important role in this approach. Despite this, system transformation to address health inequities has been slow. This is due, in part, to the lack of evidence-based guidance on how health service and delivery systems can address and measure health equity integration. Most studies focus on health equity integration in the public health sector at a provincial or national level, but less is known about integration within the health service and delivery system. More information is needed to understand how that transformation is occurring, or could occur, to make a meaningful contribution toward improving population health outcomes. INCLUSION CRITERIA: This scoping review will identify studies that describe the strategies and indicators that health service and delivery systems are using to integrate health equity and how progress is measured. Evidence from qualitative, quantitative, mixed method studies, and gray literature will be included. METHODS: This review will be conducted in accordance with JBI methodology for scoping reviews. A comprehensive search strategy, developed with a librarian scientist, will be used to identify relevant sources. Titles, abstracts, and full texts will be evaluated against inclusion criteria. Information will be extracted by two independent reviewers. Data will be synthesized and presented narratively, with tables and figures where appropriate.

Fare well to Nova Scotia? Public health investments remain chronically underfunded.

Inspired by Fiset-Laniel et al.'s (2020) article entitled "Public health investments: neglect or wilful omission? Historical trends in Quebec and implications for Canada", we assessed public health investments since the establishment of the Nova Scotia provincial health authority in 2015. We analyzed Nova Scotia Department of Health and Wellness budgets from 2015-2016 to 2019-2020 and observed that less than 1% of funding was budgeted for public health annually, an amount well below the recommendation that 5-6% of healthcare funding be spent on public health. Healthcare spending has increased annually since 2015-2016, but proportions of funding to different programs and services have remained static. Specifically, we did not observe a change in investment in public health over time, suggesting that while the government does not necessarily spend too much or too little on healthcare, it spends far too little on public health. This chronic under-funding is problematic given the high rates of non-communicable diseases in Nova Scotia and health inequities experienced within the population. The 2020 COVID-19 pandemic has highlighted the importance of public health work, and the need for a pandemic recovery plan that prioritizes investment in all areas of public health in Nova Scotia.

RéSUMé: Inspirés par l'article de Fiset-Laniel et coll. (2020) intitulé « Public health investments: neglect or wilful omission? Historical trends in Quebec and implications for Canada ¼, nous avons évalué les investissements en santé publique depuis la fondation de l'autorité sanitaire provinciale de la Nouvelle-Écosse en 2015. Nous avons analysé les budgets du ministère de la Santé et du Mieux-Être de la Nouvelle-Écosse de 2015−2016 à 2019−2020 et nous avons observé que moins de 1 % du financement était prévu pour la santé publique annuellement, un montant bien inférieur à la recommandation que 5−6 % du financement pour les soins de santé soit dépensé sur la santé publique. Les dépenses de santé ont augmenté annuellement depuis 2015−2016, mais les proportions du financement consacrés à différents programmes et services ont demeuré statiques. Spécifiquement, nous n'avons pas observé de changement dans l'investissement en santé publique au fil du temps, indiquant que tandis que le gouvernement ne dépense pas nécessairement trop ou trop peu sur les soins de santé, il dépense bien trop peu sur la santé publique. Ce sous-financement chronique est problématique étant donné les hauts taux de maladies non transmissibles en Nouvelle-Écosse et les inégalités en matière de santé qui existent au sein de la population. La pandémie de la COVID-19 de 2020 a souligné l'importance du travail lié à la santé publique, ainsi que la nécessité d'un plan de rétablissement suite à une pandémie qui priorise l'investissement dans tous les domaines de santé publique en Nouvelle-Écosse.

The Politics of Regionalization.

Regardless of their policy outcomes, strategies of regionalization are prevalent because they are politically useful. They permit governments to be seen addressing serious systemic problems in the healthcare system without fundamentally upsetting the face-to-face relationship between physicians and patients. They shift the responsibility for unpopular policies, including the consolidation of services, away from provincial governments. They can be part of a larger process of decentralizing power that is undertaken for larger, non-health-related reasons. They can also serve as a strategy of disruption that destabilizes the bases of influence enjoyed by specific stakeholder groups. For epistemological reasons, it is difficult to determine with any certainty what the specific outcomes of regionalization are. Thus, to mitigate the utilization of regionalization for politically advantageous reasons, it is useful not only to catalogue the outcomes of policies of regionalization, but also to identify whose interests are furthered, and whose are hindered, within a strategy of regionalization.

The changing contours of experimental governance in European health care.

For over a decade, beginning in the late 1990s, discussion over softer modes of governance animated academic scholarship in the fields of law, politics, and public policy. This debate was especially pronounced in Europe. Since the late 2000s, however, discussion of this approach has declined precipitously. Is the "soft governance" model dead? Or, more precisely, has the economic crisis killed it? This article argues that, to the contrary, the EU's austerity measures have made softer governance more relevant in two quite distinct ways. Administratively, new mechanisms of health policy coordination are able to provide policy solutions in a much more effective way than could more formal and rigid forms of legal harmonisation. Politically, it establishes a normative perspective which unifies actors across a number of administrative units and challenges the dominant ideological force of the market-based principles upon which the EU's austerity policies are constructed.

Breaking the Deadlock: Towards a New Intergovernmental Relationship in Canadian Healthcare.

Canadians are, at best, only "marginally confident" in the future of Canada's healthcare system (Nanos and Jenkins 2014). They are skeptical that simply spending more money can address the issues underlying Canadian healthcare, yet they also doubt the country's capacity to harness innovative strategies to improve healthcare (ibid). These issues are central to Canadians' concerns about healthcare reform: increased funding is no guarantee of better quality or access to healthcare and may reinforce inefficient patterns of health spending (Canadian Institute for Health Information 2012). For example, Contandriopoulos showed that since 2007 in Québec, total physician compensation, average physician compensation and average unit cost per service all rose quickly but the total number of services, number of services per capita and average number of services per physician were either level or declined (Contandriopoulos and Perroux 2013). However, simply pressuring provinces and territories to do more with less may also be counterproductive, because it creates immediate delivery pressures that reduce opportunities for careful deliberation of strategies for enduring and meaningful improvement. In this article, we present an approach to making the Canadian healthcare system more effective, efficient and sustainable. The program maintains the autonomy of the provinces and territories while renewing federal leadership. The core idea is to use federal healthcare transfer payments to incentivize greater efficiency, better access, better outcomes and increased health equity. Our goal is to set out this model for discussion. We acknowledge that measuring health outcomes, healthcare quality and health equity is challenging. Developing and implementing such measures will require conceptual development and detailed technical plans that are beyond the scope of this article. Moreover, we can only touch briefly on the political processes required to implement a model that balances federal leadership with provincial autonomy. Our goal here is to stimulate discussion by presenting a new model for funding and delivering healthcare.