B.C. provincial health officer Dr. Bonnie Henry listens during a press conference in Vancouver on March 14, 2020.DARRYL DYCK/The Canadian Press
Carey Doberstein is an assistant professor of political science at UBC and the author of Distributed Democracy: Health Care Governance in Ontario.
There is no doubt that British Columbia has managed to contain the COVID-19 pandemic better than Ontario and Quebec. At the end of February, B.C. had more cases than either of those two provinces. But since then, the province has managed to contain the outbreak such that its per-capita metrics are much closer to that of the smaller seven provinces. Among jurisdictions with more than 5 million people, it now has the lowest death rate in North America and Europe.
For some, this success can be ascribed to luck or circumstance. In particular, experts have associated province-by-province outcomes with the different timings of spring breaks, as well as the proximity and frequency of connections to New York, the epicentre of the outbreak in the United States in the first months.
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These circumstantial factors surely explain part of the patterns of spread in the early days. But we must not ignore the extent to which the particularities of health care governance in each province have shaped the trajectory of the virus in the subsequent weeks.
While governments in B.C., Ontario and Quebec have all managed this crisis well at the political level, it is not their partisan characteristics that are important here. Rather, it is how individual provinces have set up their health authorities and the manner in which they have structured the integration of core parts of the health system, such as primary care, hospitals and labs, that is going to be key to a comprehensive post-pandemic evaluation of their performance.
When observed from the perspective of a patient’s ability to receive essential medical care, the provinces often do not appear all that different. Yet when one peels back the outer layer, revealing the nuts and bolts of health care governance across Canada, we see considerable variation in how individual provinces have structured where authority is held, who makes those decisions, and how various parts of the health care sector (e.g. primary care, hospitals, labs, long-term care and mental health) are linked – or not.
Some provinces have a single provincewide health authority, such as Alberta Health Services; others have a few regional bodies, such as B.C.'s five, co-ordinated by one overarching provincewide agency. Others have dozens or many more localized authorities (Ontario and Quebec).
This variation is the result of the debate around whether health care governance ought to be centralized or decentralized. That has never been settled among health-policy scholars, with no clear performance superiority established from either model. It is complicated because community and personal health are complicated. There are trade-offs at each point along the spectrum with respect to democratic accountability, responsiveness, service integration and efficiency.
Yet when a pandemic hits, we want a health system that functions as an integrated system – though not necessarily a centralized one – with information systems linked across various institutions and service providers. On this measure in particular, Ontario and Quebec have long faced challenges. Quebec has numerous nested layers of health authorities at the local level, with some amount of historically preserved autonomy and independence from each other. Ontario is challenged as a result of the dismantling of Local Health Integration Networks, which began at roughly the same time the pandemic hit, forcing it into an awkward place at a crucial moment.
In British Columbia, critical integration work among the five regional health authorities is co-ordinated by the Provincial Health Services Authority, as well as associated agencies that deliver some critical programs and services provincewide, including managing supply chains, public health policy guidance, aggressive contact tracing and laboratory services. These configurations have existed for some time in response to previous disease outbreaks. Additionally, many of B.C.’s long-term care homes are operated by the health authorities and are all linked to some degree. All of this is led by Dr. Bonnie Henry, an experienced Provincial Health Officer whose decisive orders could be acted upon immediately thanks to the highly co-ordinated system.
By contrast, Ontario and Quebec are comparatively less integrated with respect to partnerships, services and administration in such crucial realms as long-term care. As a result, parts of those provinces have responded well, while other hot spots appear to be losing ground. Evidence is piling up that health officer orders in Ontario and Quebec have not had the authoritative weight and seamless implementation as those issued in B.C.
Such provincial variations are a feature, not a bug, of Canadian federalism. A comprehensive examination of the individual responses will provide us lessons for future health crises that can then be implemented with local precision and sustained public engagement, much as B.C. learned and led after HIV, SARS and H1N1. Once the COVID-19 pandemic recedes, we should not ignore any potential factors that explain why some provinces fared better than others – and health-system governance needs to be part of that conversation.
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