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Cross-Provincial Comparison of Health Care Policy Reform in Canada

Why is it so hard to reform health-care policy in Canada?  This research project was launched in the early 2000s. It is based on the findings from 30 case studies that were selected as representative of health-care policy writ-large.

Healthcare and Policy Reform

Why it is so hard to reform health-care policy in Canada:
Lessons from a Cross-Provincial Comparison of Health- Care Policy Reform in Canada

Latest update: January 23, 2014

This research project was launched in the early 2000s. It is based on the findings from 30 case studies that were selected as representative of health-care policy writ-large. A common methodology was used in assessing the 30 cases.

The cases describe and assess the nature and extent of health-care policy reform in Canada between 1990 and 2003 and set out the factors that account for the limited reform. The findings are updated to cover the 2004-2011 period.

This note provides the status of the research, lists the members of the research team, and acknowledges the sources of funding.

The views expressed herein are those of the authors and do not necessarily represent the views of the funders.

Research Status and Publications

Expand this box to see the project outputs listed under four headings: main findings, 30 case studies, background studies and other papers and presentations.

The project entailed an assessment of the nature and extent of health-care policy reform in Canada since the beginning of the 1990s, sets out factors that account for the meagre reform that has occurred since then, and analyzes the prospects for reform going forward. The volume is based on studies of a representative series of policy-reform issues drawn from four policy categories: governance arrangements, financial arrangements, delivery arrangements, and policy content. From these categories six issues were selected: regionalization, needs-based funding, alternative payment plans for primary care physicians, for-profit delivery, waiting lists, and prescription drug coverage.  Each of these six issues was studied in five provinces: Alberta, Saskatchewan, Ontario, Quebec, and Newfoundland and Labrador. Data were collected using key-informant interviews, supplemented by a review of publicly available documents about these policies.

Each of the 30 case studies involves: description of the context within which the case was studied; the nature and extent of reform; and analysis of the factors that influenced policy-making processes at the various stages of the decision process (to the extent that there was reform). It thus focuses on whether and why an issue became an agenda item that required government decision; and for those cases in which a reform decision was taken, the factors that shaped the policy choice.  The case studies focus initially on the 1990-2003 period (primarily a period centre and left-of-centre provincial and federal governments) and the analysis is extended to the 2004-2011 period (primarily a period of centre and right-of-centre governments).

Each of the cases is analyzed in relation to a specified definition of reform. These definitions are based on the consensus about the desired nature and extent of reform as set out in the reports of the many provincially and federally appointed commissions, task forces and advisory groups beginning in the second half of the 1980s. The data are then analyzed from cross-issue, cross-provincial, and cross-ideology perspectives.

The main findings are set out in Paradigm Freeze: Why It Is So Hard to Reform Health Care Policy in Canada. It is published by McGill-¾ÅÐãÖ±²¥ Press for the Institute of Intergovernmental Relations in the ¾ÅÐãÖ±²¥ Policy Study Series, School of Public Studies.

Copies can be ordered from

All case study authors used the same methodology for consistency. The 'inputs' from their case studies were used for intra-provincial analysis as reflected in chapters 3-7 and also for cross-province and cross-issue in chapters 8-11 of Paradigm Freeze: Why It Is So Hard to Reform Health Care Policy in Canada.

The case studies are available for download below this paragraph. Each author had the freedom to organize his or her findings in whatever style he or she preferred. Thus, these papers vary in presentation and style but share common objectives and analytic frameworks. Some of the 30 cases have been published in peer-reviews journals, while others remain unpublished. Links to published works are provided; for those papers labelled "unpublished," they may not be cited, reproduced, or distributed without permission of the lead author

Alberta Case Studies

  • Church, John and Neale Smith. 2006. "Health Reform and Privatization in Alberta." Canadian Public Administration, Vol. 49, No. 4 (Winter): 486-505. DOI: 
  • Church, John and Neale Smith. 2008. "Health Reform in Alberta: The Introduction of Health Regions." Canadian Public Administration, Vol. 51, No. 2 (June): 217-238. DOI: 
  • Church, John and Neale Smith. 2008. "Shifting the Lens:  The Introduction of Population-Based Funding in Alberta." Healthcare Management FORUM, 21(2) (September): 36-42. DOI: 
  • Church, John and Neale Smith. 2009. "Health Reform and Wait Times Policy in Alberta under the Klein Government." [PDF 420 KB] Canadian Political Science Review, Vol.3, No.4 (December): 63-84.
  • Church, John and Neale Smith. 2013. "Health Reform and Drug Policy in Alberta." [PDF 192 KB] Unpublished.
  • Church, John and Neale Smith. 2013. "The Introduction of APPs in Alberta." [PDF 335 KB] Unpublished.

Saskatchewan Case Studies

Ontario Case Studies

Tables available for download [PDF 331 KB].

The tables in this document are cited in the following chapter:

Lavis JN, Pasic D, Wilson MG. Health-care reform in Ontario: More tortoise than hare? Chapter 5 in Lazar H, Lavis JN, Forest P-G, Church J (2013). Paradigm Freeze: Why It Is So Hard to Reform Health-Care Policy in Canada? Montreal and Kingston, Canada: McGill-¾ÅÐãÖ±²¥ Press; 2013, p. 89-111.

The tables are made available here for those who want additional details about each of the cases described in the aforementioned chapter. They are the tabular equivalent of the case-specific reports prepared for provinces other than Ontario. The tables can be cited as follows:

Lavis JN, Pasic D, Wilson MG. Health-care reform in Ontario: More tortoise than hare? - Online tables for chapter 5 in Lazar H, Lavis JN, Forest P-G, Church J (2013). Paradigm Freeze: Why It Is So Hard to Reform Health-Care Policy in Canada? Hamilton, Canada: McMaster University Program in Policy Decision-making; 2013.

Quebec Case Studies

Newfoundland and Labrador Case Studies

The following are some of the published outputs and presentations of team members arising from the project research:

Project Team

Project Leader/Coordinator

  • Harvey Lazar, University of Victoria and ¾ÅÐãÖ±²¥ Institute of Intergovernmental Relations, Principal Investigator

Associate Coordinators

  • , McMaster University
  • Pierre-Gerlier Forest, Johns Hopkins University

Provincial Coordinators / Principal Provincial Chapter Authors

  • Alberta - , University of Alberta
  • Saskatchewan - , University of Regina
  • Ontario - , McMaster University
  • Quebec - , Université de Montréal;  , Université Laval
  • Newfoundland and Labrador - , Memorial University

Issue Coordinators

  • Regionalization - , Memorial University
  • Needs-Based Funding - , University of Regina
  • Payment Plans - , University of Alberta
  • For-Profit Delivery - Alina Gildiner, Ministry of Health and Long-Term Care, Ontario (formerly McMaster University)
  • Waiting Lists - , Statistics Canada
  • Drug Plan Coverage - , Université de Montréal

Literature Review

  • 2003. Theoretical Literature Review, Carleton University
  • , Review of Grey literature, Saskatchewan Institute of Public Policy, University of Regina

Administrative Officer

  • Mary Kennedy, ¾ÅÐãÖ±²¥ Institute of Intergovernmental Relations

Website Coordinator

  • Ryan Zade, ¾ÅÐãÖ±²¥ Institute of Intergovernmental Relations

Research Assistants

¾ÅÐãÖ±²¥

  • Aaron Holdway 2002-2004
  • Ryan Zade 2006-2008, 2012-2013

University of Victoria

  • Julia Diamond 2011-2012
  • Bryan Gulka-Tiecheko 2011-2012
  • John Schmid 2010-2011
  • Jessica Hartog 2010-2011

McGill University

  • Daniel Wolfe 2011

University of Alberta

  • Neale Smith 2003-2006
  • Deborah Lafleur 2003-2006

University of Regina

  • Michael Ducie

McMaster University

  • Dianna Pasic 2003-2006

Université de Montréal

Memorial University

  • Jeff Braun-Jackson 

Editorial Services

  • Ellie Barton
  • Val Jarus
  • William Church, Q.C.

Project Funding

  • the  and , and 
  • the  for financial support in communicating and disseminating the research results.