Multiculturalism and Health HEALTH CARE REFORM AND THE PARADOX OF EFFICIENCY: “WRITING IN ” CULTURE

Widespread global migration is occurring at the same time that health care delivery systems in Western nations are undergoing major restructuring. The call for health care to be more efficient, economical, and responsive to diverse cultural populations has come from several sectors, including governments and researchers. This has led to policies to address perceived deficiencies in health care services. The authors draw on their research at health care institutions in a western Canadian city to probe, first, how the concept of culture is interpreted within organizations; and second, how culture is “written into health systems ” as they undergo restructuring. Meanings and interpretations of culture are not transparent; moreover, “writing in ” culture is not simply a matter of health care providers learning about their clients’ “belief systems ” and being sensitive to these beliefs. Belief systems and people’s experiences of the care they receive are negotiated within highly complex “organizational cultures, ” located in broader macroeconomic and political structures, and discourses that shape how health care systems are organized. The authors consider whether current discourses on cost con-tainment are in competition with providing equitable health care services to diverse client populations. Health care delivery systems in Canada have undergone major restructuring since the late 1980s (1, 2). In 1993 Evans noted that, “in the last five years, every province of Canada has established a Royal Commission or other major inquiry into its health care system ” (2, p. 35). Recommendations from these commissions gave way to major restructuring of health care systems across the country. Restructuring of health care systems is not unique to Canada, Evans tells us. In fact, Creese, in discussing global trends in health care reform, has argued that “reform is in progress in countries at all levels of development ” (3, p. 317). These reforms are taking place at the same time as major demographi