The ‘Poor Cousin’ of Health Policy

Abstract

As Canada’s older demographic has expanded in recent decades, increasing attention has been focused on home care as part of a broader trend in health reform emphasizing Aging-in-Place. However, despite this, public home care policies and programs across Canada have generally stagnated over the same period, struggling to keep up with growing demand. To help understand why this has happened, this study compares the evolution of home care policies in Ontario and Saskatchewan from the late 1980s to early 2000s using a process-tracing approach. It finds that policy legacies established by early institutional decisions in each province’s home care program shaped the ideas of policymakers and empowered some interest groups over others to cause divergent home care reform choices in response to common challenges experienced within each province’s health system. These reform trajectories set Ontario and Saskatchewan on different reform paths,which occurred despite increased interest in seeing home care play a greater role in each province’s health system. However, the study also identified provincially distinct dynamics by which home care found itself temporarily the focus of increased attention from governments. Specifically, distinct legacies of policy decisions made in the early years of each province’s home care program formation led to the establishment of different ideas regarding home care’s potential as a cost-saving alternative to acute care. These provincially distinct decisions in home care program development also established a unique arrangement of stakeholders in home care, who had differing degrees of influence on policy directions considered during the study period. The thesis concludes by suggesting that home care’s historically marginal role as the “poor cousin” of provincial healthcare systems is the result of a lack of sustained interest from policymakers in investing in home care for the sake of home care, rather than as a means of achieving ulterior goals in health system reform.