Provincial health care blocks clamour for credibility
The formation of Local Health Integration Networks (LHIN) in Ontario marks an important new chapter in the organization and delivery of health care in Canada's largest province. Although technology and the emergence of e-health are important drivers of this experiment in regionalization, governance will ultimately be the key determinant of success or failure.
Why create a set of LHINs in the first place? First, size matters. Ontario is larger both geographically and demographically than most countries, including those of Scandinavia that are often regarded as e-government leaders. In these Nordic countries, it is not the national government that is primarily responsible for health care - it is the regions. The Ontario case is thus analogous.
Secondly, the scope of innovation and interoperability also matters. While Ontario has an e-health strategy managed from within a Toronto-based ministry, the actual deployment of new technologies and the benefits derived from new collaborative mechanisms are inherently more localized. As much as e-health might be viewed as a framework of provincial systems and standards, it will be up to regions and their various clinics, hospitals and other health care actors to instigate frontline change.
In essence, the LHIN model reflects one of the paradoxes of new information and communication technologies, namely their inherent ability to either centralize or decentralize power. In the realm of e-health there are undoubtedly pressures to centralize, in order to forge more interoperable information systems and realize efficiencies across the province as a whole. Yet managing the entire provincial health care system as a single enterprise also has limits due to the aforementioned importance of flexibility and responsiveness.
To strike the right balance, the LHINs thus face a dual governance challenge of accountability on the one hand and legitimacy on the other. Both of these dimensions are very much interrelated, rooted in the capacity of the LHIN to mobilize stakeholders within a given region to orchestrate both territorial-based and virtual improvements in health care performance.
In terms of accountability, to whom the LHIN is ultimately responsible is a key concern. Each network is led by a board of directors that, in the spirit of good corporate governance, includes a separation between the chairperson and CEO functions. Key stakeholders are also represented on the board and an open nomination process allowed for the community to put forth candidates to serve.
Nonetheless, it was the provincial government that retained a strong degree of control by appointing chairpersons, chief executives and a number of board member appointees. The budgetary envelopes for the LHINs are for the time being extremely modest: key decisions about resources remain firmly in the hands of the minister and his (largely) Toronto-based officials.
Such control is justified by the need to carefully put in place the conditions for creating these new mechanisms within a province-wide rubric. It bears noting here that Ontario is the only province in the country not to have formalized regional bodies with health care mandates. The change is thus an important one, and gradualism may well be called for.
At the same time, however, with respect to legitimacy, such gradualism may not suffice to achieve real results. It is only if the LHIN is viewed as a forum with authority and clout that stakeholders will become engaged. There are also important, unanswered questions about whether some form of direct democratic involvement on the part of the public will eventually be introduced, to strengthen accountability in the communities served by each LHIN.
There is much potential value in the LHIN evolving into something more than a technocratic chamber focused on the service and information architecture of health care delivery. The notion of a smart community, imported from California and introduced by Industry Canada during the 1990s, embraced the underlying importance of geographic proximity, virtual connectivity and human collaboration in fostering new opportunities for economic and social development.
Although e-health must be coordinated and supported both provincially and nationally, it is locally where meaningful change begins. Beyond forging better ties across existing health care stakeholders, the LHIN can also serve as an important focal point for public input and debate - central elements of a citizen-centric approach to governance renewal.
Top-down incremental management or more holistic bottom-up experimentation? The coming provincial election will ideally spark more public deliberation on this critical choice on the future of the LHIN.
Jeffrey Roy is associate professor in the School of Public Administration at Dalhousie University. He can be reached at roy@dal.ca
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