Table Of ContentDISTRIBUTED DEMOCRACY
Health Care Governance in Ontario
The Institute of Public Administration of Canada Series
in Public Management and Governance
Editors:
Peter Aucoin, 2001–2
Donald Savoie, 2003–7
Luc Bernier, 2007–9
Patrice Dutil, 2010–18
Luc Juillet, 2018–
This series is sponsored by the Institute of Public Administration of
Canada as part of its commitment to encourage research on issues in
Canadian public administration, public sector management, and pub-
lic policy. It also seeks to foster wider knowledge and understanding
among practitioners, academics, and the general public.
For a list of books published in the series, see page 219.
Distributed Democracy
Health Care Governance in Ontario
CAREY DOBERSTEIN
UNIVERSITY OF TORONTO PRESS
Toronto Buffalo London
© University of Toronto Press 2020
Toronto Buffalo London
utorontopress.com
Printed in the U.S.A.
ISBN 978- 1- 4875- 0725- 1 (cloth)
ISBN 978- 1- 4875- 3588- 9 (EPUB)
ISBN 978- 1- 4875- 3587- 2 (PDF)
_____________________________________________________________________
Library and Archives Canada Cataloguing in Publication
Title: Distributed democracy : health care governance in Ontario / Carey
Doberstein.
Names: Doberstein, Carey, author.
Series: Institute of Public Administration of Canada series in public
management and governance.
Description: Series statement: Institute of Public Administration of Canada
series in public management and governance | Includes bibliographical
references and index.
Identifiers: Canadiana (print) 20190224088 | Canadiana (ebook) 20190224266 |
ISBN 9781487507251 (cloth) | ISBN 9781487535872 (PDF) | ISBN
9781487535889 (EPUB)
Subjects: LCSH: Public health administration – Ontario – Evaluation. |
LCSH: Public health – Political aspects – Ontario. | LCSH: Public
health – Ontario – Citizen participation. | LCSH: Medical
policy – Ontario – Evaluation.
Classification: LCC RA450.O5 .D63 2020 | DDC 362.109713 – dc23
___________________________________________________________________________________
This book has been published with the help of a grant from the Federation
for the Humanities and Social Sciences, through the Awards to Scholarly
Publications Program, using funds provided by the Social Sciences and
Humanities Research Council of Canada.
University of Toronto Press acknowledges the financial assistance to its
publishing program of the Canada Council for the Arts and the Ontario Arts
Council, an agency of the Government of Ontario.
Funded by the Financé par le
Government gouvernement
of Canada du Canada
Contents
Foreword vii
Acknowledgments xi
List of Abbreviations xiii
1 Introduction 3
2 The Democratic Arenas Framework 20
3 The Evolution of Health Care Governance in Ontario 41
4 Procedural Decision- Making Bodies That Enable and
Constrain LHINs 62
5 LHINs as Mandated Decision- Making Sites 90
6 LHIN Advisory Committees and Public Engagement 115
7 A Democratic Arenas Analysis of LHINs 148
Appendix 179
Notes 181
References 203
Index 211
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Foreword
The provision of health care services is one of the most important func-
tions of the modern welfare state. Few areas of public administration
touch the lives of citizens so directly, significantly, and universally,
which helps explain why they care so much about the state of health
care. Health services also consume a vast amount of public resources.
According to the Canadian Institute for Health Information, national
annual health expenditures are projected to reach $264 billion in 2019,
representing nearly 12 per cent of Canada’s GDP. About 70 per cent of
this money is spent by government. This year, the Ontario government
will spend over $60 billion to offer health care services to an aging and
very diverse population, a sum representing over 40 per cent of the
province’s total program spending.
Given the importance of health care for citizens and governments,
the governance and organization of health services constitute a cen-
tral challenge of public administration, which is partly why this book
by Carey Doberstein is such a welcome addition to the IPAC Series in
Public Management and Governance. Beyond the impact of compet-
ing organizational designs and models of service delivery on health
outcomes, core issues of democratic government are at stake in the
governance of health care. For example, where should decision-mak-
ing authority be located to ensure an optimal combination of effective
stewardship, central control and planning, attentiveness to local needs
and conditions, efficient delivery, and effective accountability? To what
extent, and how, should elected officials, public managers, citizens, phy-
sicians and other health professionals, patients, and other stakeholders
be involved in decisions about service availability and delivery? Given
the bewildering complexity of health systems, how can we ensure that
they still permit democratic control, citizens’ input, and accountability?
viii Foreword
In this timely book, Doberstein helps to tackle such questions by
providing a sophisticated and nuanced assessment of one of the lat-
est attempts at improving the governance of health services in Canada:
the creation of Local Health Integration Networks (LHINs) by the gov-
ernment of Ontario in 2004. Despite their name, LHINs are essentially
regional semi-autonomous Crown agencies, answerable to the minister
of health and her department but also governed by their own corporate
board, tasked with ensuring the coordination of health service provid-
ers in their region. Benefiting from some decision-making authority
and a collective budget of about $25 billion, they are also meant to
decentralize and democratize health care administration by providing
citizens and stakeholders with the opportunity to influence policy and
investment decisions at the regional level. In sum, LHINs are at the cen-
tre of a complex system of regionalized health care governance.
In the following pages, Doberstein offers a systematic and balanced
examination of one of the key aspects of the LHINs: their democratic
character. Through a close examination of their legal and institutional
framework, their governance practices, and their relationships with the
health ministry, stakeholders, and citizens, he shows that, while the
LHINs sometimes succeed in expanding opportunities for stakeholder
input, they also largely remain under the control of the government
and its health department, often fail to ensure meaningful and inclusive
local representation and participation, ensure only limited coordination
across decision and planning venues, and at times suffer from weak or
dysfunctional accountability mechanisms. In sum, despite some nota-
ble democratic advances in the governance of provincial health care,
the LHINs are falling short of their promise due to a combination of
design flaws and poor local choices in governance practices.
For readers who follow debates about health care policy and gov-
ernance, shortcomings in the LHINs’ operations may not be surpris-
ing. Like other experiments of regionalization of health services across
the country, Ontario’s LHIN system has attracted its share of criticism,
notably for being excessively bureaucratic and complex. In fact, in April
2019, the Progressive Conservative government of Doug Ford enacted
another restructuring of the provincial health care system that will
recentralize its governance by creating Ontario Health, a new powerful
“superagency” that will oversee the coordination of health care across
the entire province and largely absorb the fourteen LHINs (as well as
other agencies) over the next three years. However, Doberstein’s anal-
ysis provides a much more systematic and nuanced assessment that
goes well beyond the typical critique and will allow the reader to much
Foreword ix
better understand the strengths and weaknesses of the LHINs as a
model of regionalized health care governance.
As such, the book provides insights that will not only be valuable
for understanding health care governance in Ontario over the past fif-
teen years as well as passing judgment on whether current reforms are
likely to address current flaws. By conceptualizing health governance
as a system of interrelated democratic arenas through which decision-
making authority is (more or less) distributed, Doberstein also provides
a conceptual framework that can serve to guide the analysis of the dem-
ocratic governance of health systems of other jurisdictions. In fact, the
book will also be of interest to people working in other policy areas
where network-based distributed governance is being attempted or
contemplated. At a time when network governance and the co-creation
of public services are among the most hotly debated issues of public
administration, Distributed Democracy offers conceptual tools and ana-
lytical insights that are relevant to scholars and practitioners in most
areas of public management and governance. In sum, it is a timely book
that undoubtedly speaks to contemporary health policy debates, but
that addresses fundamental problems that specialists of public admin-
istration will have to contend with for years to come.
Luc Juillet, PhD
University of Ottawa
Editor, IPAC Series in Public Management and Governance
