Health and Health Policy

Health and Health Policy FEDERALISM AND HEALTH POLICY: THE DEVELOPMENT OF HEALTH SYSTEMS IN CANADA AND AUSTRALIA. Gwendolyn Gray. Toronto: University of Toronto Press. 1991. 281 pp. CANADIAN HEALTH CARE AND THE STATE: A CENTURY OF EVOLUTION. Ed. C. David Naylor. Montreal: McGi/1Queen ' s University Press, 1992. 241 pp. DOCTORS IN CANADA: THE CHANGING WORLD OF MED ICAL PRACTICE. Bernard Blishen. Toronto: University ofToronto Press, 1991. 195 pp. RESTRUCTURING CANADA'S HEALTH SERVJCES SYSTEM: HOW DO WE GET THERE FROM HERE? Eds. Raisa B. Deber and Gail G. Thompson. Toronro: University ofToronto Press, 1992. 420 pp. (Proceedings of rhe Fourrh Canadian Conference on Hea/rh Economics, Toronto, A11g11s1 27 ro 29) Canada's system of universal public health insurance has been one of the nation 's most succes sfu l and overwhelmingly popular public programs. The program works very well, especially when compared to most other systems throughout the world. It has been successful in equalizing access to health care services and has managed to contain expenditures on health care for an extended period of time. The public health insurance program has also played an important role in nation-buildin g with its emphasis on equality among the citizens ofCanada. At present, the health care policy agenda in Canada is being driven by a set of interre lated issues, none of which is particularly new or unique to Canada. These issues are in the areas of cost control, demographic change in the population, the proliferation of technology, manpower planning, and improving the efficiency of health care delivery. The four books considered here provide a variety of analyses of these issues and the health care market from a number of different perspectives, namely Journal ofCanadian Studies Vol. 29. No. J (A111011111e 1994 Fall) political, historiographical, sociological and economic. In Federalism and Healrh Policy: The Development ofHea/rh Systems in Canada and Australia, Gwendolyn Gray provides us with a well-researched, well-presented and detail ed comparison of the development of health care policy in two federal systems. In the process, Gray examines the validity of two competing theories of federalism, the "orthodox" and the ."revisionist" theories. The first theory, attnbuted to James Madison, suggests that the division of power in a federal state restricts the extent to which government can intervene effectively in economic and social policy; in this sense federalism would act as a barrier to change. The s~cond theory, associated primarily with Pierre Trudeau and Alan Cairns, suggests that the division of power in a federal system contributes to the expansion of government and may, under certain conditions, lead to innovation in policy development. As her method of analysis, Gray employs a " most-similar system" comparison between Canada and Australia. The main variable under examination is the i~pact of insti tutions as major determinants of government activities and policy development. Gray recognizes, however, that while institutions are central to theories of federalism, other factors interact with institutional structures to influence government policy. It is in this context that the development of health policies in Canada and Australia are examined and compared. Gray provides an historical overview of the development of National Health Insurance in Canada and argues that policy development s in Canada have been quickly advanced by th e successful introduction of comprehensive measures at theyrovincial level that were later adopted nauonaily. The National Health Insurance program developed from a combination of federal financial support and respect for provincial responsibi lities. Gray also argues that centralization of power was not a necessary condi tion for such socia l policy reform. She provides examples of 169 this in her examination of the costcontainment policies of Canadian governments after the introduction of National Health Insurance. During the passage of the Canada Health Act (1984), the federal government was seen to be preserving a popular national program without having to take responsibility for its implementation. It was the provinces' responsibility to reach agreements with provincial medical associations and to implement the programs. The federal division of responsibility provided flexibility at both levels of government, a division of responsibility which facilitated the subsequent banning of extra-billing. There was sufficient time for the provinces to decide what action to...