Steering and Rowing in Health Care: The Devolution Option?

Joanna Erdman


Publicly funded health care systems are often the subject of heated policy debates. All too often (particularly in Canada), these debates focus on the prohibitive costs, the resultant taxation levels, and the questionable efficiency and outcomes associated with a publicly funded system. Moreover, the institutionalization of the system and the entrenchment of its many stakeholders make effecting change particularly difficult. In this article, the authors begin with an assessment of the drawbacks of the Canadian health care system in the federal-provincial context and its resulting gaps in governance (steering), in management (rowing), and in overall accountability (apart from that offered by periodic elections). They conclude that because of the above factors and the public's personal investment in a perceived health care entitlement, policymakers tend to avoid long-term changes to the system in favour of such short-term solutions as increased funding or reductions in funding services. If fixing health care is the goal, governments must embrace more fundamental change. Devolution is a process through which governments give up their hold on the detailed management of the health care system, in exchange for more involvement in its governance. In this way, it allowed the government to steer - by defining values, setting goals and objectives, and evaluating outcomes and efficiencies of the system - while allowing those that deliver health care to determine how best to do so (in other words, allowing the rowers to row). In light of the successes and failures of devolution in other jurisdictions, the authors then present a model for devolution that they argue will allow the Canadian health care system to flourish. Although devolution is only one part of the solution, it is a fundamental part.

This paper was co-authored with Colleen Flood, University of Toronto ( and Duncan Sinclair, University of Toronto.


Health Law


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