From National Accords to Bilateral Agreements: Transforming Canadian Health Care Intergovernmentalism

This paper examines the transition from the “era of the health accords†(from 2000 to 2017) to the new regime of individual bilateral agreements between Ottawa and each of the provinces and territories, allocating federal health transfers and setting agreed-upon health-reform priorities in each jurisdiction. The paper argues that the health accords of 2000, 2003 and 2004 were essentially unsuccessful for a number of reasons. First, they tended to raise expectations among the public, health system actors and health policy experts about the ability to transform health care in Canada in a relatively short period of time. This was, in part, a result of the accords’ very broad and general commitments to change, but also their lack of recognition of the barriers to change that exist within the system. Second, and related to the first, attention was paid mostly to the amount of the transfer from the federal government to the provinces and territories, rather than to how those dollars were to be spent. At best, governments bought only a modest amount of change in the system, despite the billions of dollars of new investment. Unlike other industrialized federations, Canada appears to be the only one that relies on an ongoing, highly politicized process of intergovernmental diplomacy to negotiate the fiscal relationship in health care. This, combined with a somewhat amorphous and changeable understanding of the federal government’s overall role in health care, complicates the process of reform and heightens the political stakes around the negotiations. The new model of bilateral agreements negotiated under an umbrella statement of common principles around health-reform priorities may yet prove to be an improvement in both process and outcomes. Bilateralism can serve to de-escalate the political stakes inherent in the federal-provincial diplomacy around Canada’s most popular social program, by moving away from the “grand bargains†that characterized the accords. In short, there will be less opportunity for the kind of political rhetoric that unduly raises expectations of rapid change. More importantly, the bilateral agreements, although far from perfect, may actually better serve to focus attention on the specific health-service organization and delivery issues the provinces and territories intend to improve, restructure or expand. Under very broad principles such as “improving access to mental health and community care,†the bilateral agreements articulate some very clear plans about specific approaches, programs and policies on which the transfers will be spent. This should provide a much greater opportunity for the Canadian public to hold governments to account for progress in those areas, something the accords never really managed to do. Going forward, there is still room for improvement. Some provincial plans are decidedly vague, and governments should be urged to be more specific in their commitments and intentions. Common indicators continue to be difficult to develop, although big strides have been made in recent decades. Governments would be well advised to talk seriously and openly about the challenges and barriers to change that exist within the system and, in doing so, marshal public support to dismantle them. And the federal government itself needs to actively engage in assisting jurisdictions in learning from and adapting the successful reforms and initiatives of other jurisdictions. This could be an act of true system stewardship.