Discourses and Practices of Health System Regionalization: Dominant, Contested and Absent Themes

Policies of health system regionalization with agendas of increased public participation were significant components of Saskatchewan health reforms of the 1990s. Regionalization entailed both devolving and centralizing powers from provincial ministries and local facility boards to newly created regional boards comprised of local community members who would now be in charge of planning and delivering local health services. An under-considered area in policy studies is the interpretation and agency of central actors charged with taking government announcements and public policy amendments and enacting these into day-to-day practices. This dissertation explores this interpretive space. Based on interviews with 11 Health Authority Board Chairs, 8 health region CEOs, 8 Ministry of Health officials, and 5 members of Advisory Networks, this research examines how these actors framed and practiced “regionalization” and “public participation” policies. Drawing on a discourse analysis utilizing NVIVO software, my analysis revealed that the central actors framed their interpretations and practices of regionalization within technocratic logics: regionalization and public participation policies were interpreted and constructed as routes to efficient and effective services. Although population health logics framing the policies in terms of their empowerment potentials were called on early in the reforms, these logics no longer appear in the discourse and practices. Democratic traces and concerns of local representation and accountabilities persist. While largely accommodated and hybridized within technocratic framings, sites of democratic-technocratic contestation remain. In keeping with broader transformations, publics are increasingly called upon to participate not as citizens but as responsible patients and families, with individualizing patient, client, and consumer positions being prioritized over collective positions of communities and populations. Technical accuracy appears to takes precedence over public accountability and engagement. Experts make decisions, with input provided by reflexive publics, and the ultimate goal is an efficient system