University of Toronto – UniversityCollege – Health Studies

UNI 211H1S -- Health Policyin Canada

Winter 2015

Instructor: David Langille 647-280-7747 C

Teaching Assistants: Ghazal Fazli

and Madelaine Cahuas

Course Dates: January 5 – March 30 Class Hours: Mondays 2:00–5:00 pm

Class Location: HI-Cart (St. Hilda's College Cartwright Hall - 44 Devonshire Pl.)

Office: University College D302 Office Hours:By appointment

Course Description: This course introduces students to Canadian health policy. It examines the policy making process; policy making in the Canadian context, and specifically the development of Canadian health policy; and explores current debates over the social determinants of health.

Health is increasingly contentious with Canada’s aging population, advancements in medical technology, and government fiscal restraints. It is a challenge to achieve the best health given the limited resources available, and to ensure that health care is fair, equal, and accessible. The course will provide analytical tools for understanding health policy, offer an overview of current policy issues, and explore their relationship to social inequality, gender, and race.

Course Structure: The course will cover: 1) the policymaking process in general and in the Canadian context; 2) the Canadian health system and its development; 3) current health reform debates and issues, and 4) how to advocate for improvements in health policy.

Course Objectives: Through readings and classroom discussions, the course will provide students with the knowledge skills to:

1) appreciate the social, political, and economic dimensions of health policy and policymaking;

2) critically analyse and evaluate current health policies in Canada;

3) consider emergent issues in Canadian health policy and current health reform issues;

4) build on students’ experience and skills in policy decision-making and advocacy.

Organization:Each three hour class will:

1) offer an analytic framework to understand health policy,
2) illustrate with examples of good or bad policies, and
3) discuss how we might advocate to improve health policies

Required texts:

Bryant, Toba (2009) An Introduction to Health Policy. Toronto: Canadian Scholars Press. ISBN 9781551303499

Fierlbeck, Katherine (2011)Health Care in Canada: A Citizen's Guide to Policy and Politics. Toronto: University of Toronto Press. ISBN 9781442609839

Laverack, Glenn (2013) Health Activism: Foundations and Strategies. Sage: London. ISBN 9781446249659

Recommended text:

Meili, Ryan,A Healthy Society: How a Focus On Health Can Revive Canadian Democracy. Saskatoon: Purich. ISBN: 978-1895830-637

All of these books are available for 3-hour loan from the University College Library (Course Reserves). There are additional articles listed in the Course Outline and/or available from Blackboard.

Note - If you have not taken UNI209, please read by Mikkonen, Juha and Dennis Raphael (2010) Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management – which is available on the internet for free at

GRADING SCHEME

  1. Answers to Questions on the Readings – 5 x 10 = 50%
  2. Essay Option (in place of 3 answers) – 25% and Outline – 5%
  3. Advocacy Assignment – 30%
  4. Test - 20%

Total - 100%

  1. Answers to Questions on the Readings– These assignments encourage you to read your text each week and come to class prepared for a good discussion of the material.

You are asked to prepare written answers to 5 questions, each being worth 10% of your grade. 5 answers x 10% = 60% (You can answer up to 7 questions (max!) and we will count the top 5.) Your answers have to be 450 to 700 words (roughly 2 to 3 double-spaced pages), and must be handed in to the class/tutorial when it is due. Submit the summaries in hard copy at the beginningof class.

We prefer typed, but will accept hand written answers. However, we will not accept them being handed in late, as that defeats the purpose of this assignment, which is to encourage you to read your text and be prepared to discuss the content. If you are unable to make it in, you can submit your answer by email ONCE if it's received before 12pm.

Your answers should thoroughly cover the content of the text, although you are welcome to go beyond the text to draw on other material and your own ideas. (Citations are only needed for outside material – not for your text book.) If your answer shows evidence that you have read the material you may earn 5/10, if you give a clear answer to the question you can earn 6/10 or 7/10, and if you can offer an outstanding summation of the material(s) you can earn an “A” or 8 or 9 or even 10. Here are some tips for writing these weekly summaries:

What does an ‘A’ assignment look like?

Content

  • Answers all elements of the question.
  • Shows advanced understanding of the material and an ability to articulate this understanding clearly and succinctly.
  • Uses own words to explain the concepts from the text. This is particularly critical when providing definitions - the more you are able to use your own words rather than relying on quotes, the more obvious it is that you understand the concepts.
  • Provides a context for the discussion.
  • Integrates your learning from previous weeks and show a developing understanding of the field of health policy.
  • Expresses some unique thoughts on the material or uses outside sources or examples to enhance the paper. Always identify any personal opinion as such and provide justification for why you hold that opinion. Fully explain the examples that you raise and how they are relevant.

Structure

  • The summary is well structured with the use of paragraphs and a brief introduction and conclusion.
  • There is a clear and logical flow with good transitions between ideas.
  • Minimal grammatical/spelling errors and appropriate academic writing style.
  1. Essay Option - You have the chance to explore an area of your own interest in an essay rather than answer three of the smaller assignments.

You will be required to submit an outline and annotated bibliography beforehand, worth 5%. It will be due in class on Feb 9. The outline should include a 150 word description of your topic and how you will approach it, and identify and describe at least 5 sources of material, with a couple of sentences to make clear why each source is relevant or useful for your paper. The essay itself will be due on March 15, and is worth 25%. It should be 2500-3500 words, or roughly 10-15 pages double-spaced.

3. Advocacy Assignment – The Health Advocacy Project calls on you to resist the siren call of science. There are those who study public policy as a science, but they are largely irrelevant to the public policy debates that actually determine public policy. Sadly, public policy is not determined by rational scientific methods, nor by imitating best practices from around the world, but by the naked exercise of power, often in the pursuit of profit. Therefore, our best hope as citizens and students of health policy is that we are able to mobilize our democratic power and act collectively to control state institutions in the public interest -- to make them instrument of popular rule.

If you accept this premise, you need the skills to become political activists and community organizers, rather than be high priests of public policy.That's the best way to improve the social determinants of health – to seek excellence in citizenship, in public service and collective action.

The assignments vary from year to year depending on the political timetable and the policy agenda. Students have optionsfor either individual or group projects.

Advocacy Assignment Proposal -- Whichever of the options you chose below, you need to get started early in the term. Please submit a one page (roughly 250 words) proposal that clarifies which option you have chosen, the specific topic you are addressing, who you are working with, your own role or goal and those of your group members (if you are working with a group). This proposal is worth 5% of your grade, and is due on January 26.

Group Project – Personal Journal -- If you work on a group project we need some objective criteria to assess how much you contributed to your project and what you learned in the process. Please present us with a journal that offers:

  • A summary description of what your group accomplished (150 words) – you are welcome to cut and paste from any documents you generated.
  • What you did for the project, step by step, i.e. time spent organizing, writing, researching, contacting people.
  • A critical assessment of what you and your group accomplished or did not accomplish (at least 150 words)
  • What you learned from participating in the project (150 words).

Your report should be roughly 4 pages (1000 words) plus appendices if necessary or appropriate. It need not be formally written. It will be due on Monday, March 23.

Alternatively, you can work individually or in groups to survey the health policy community in Ontario, i.e. to investigate one of the many interest groups or organizations that is trying to shape health policy in this province in order to know their policy priorities, their power base, their communication methods and the overall effectiveness.

In this case, you have two options:

1. Choose one of the social determinants of health, and identify the policy community involved ie, describe the key actors and groups of actors who make policy decisions in this area eg, the government agencies, elected officials, corporations, non-governmental organizations, academic experts and policy consultants. List them, and where possible, write a few sentences to describe them. You are encouraged to assess the balance of forces, ie. which actors wield the most influence, and why do they have more influence than others?
2. Compare and contrast two organizations involved in health policy in Ontario in order to determine which wields the most influence, and why does it have more influence than the other. These could be organizations working on the same issue or from widely different areas of the policy community. You will have to:

a) Describe the organizations - in terms of the number of employees, their annual budget, who they represent, their goals, objectives and main activities.

b) Find out what policies they advocate and how they do so. Were they active in the last election, and if so, how?

c) How do they communicate their positions, before and after the election eg. are they meeting with the Premier, the Minister of Health, the opposition leaders or their health critics, or with their local candidates. What print materials have they produced? What materials are they sending to their members, or to the media? What use are they making of their website or other social media? Offer some analysis of the material that you gather.

Whether you chose Option 1 or Option 2, be as concrete and specific as possible in your analysis of who has the most power and why. This may require you to speak with actors in the policy community -- it will be difficult to find all the answers in the library or on the internet. Treat such interviews as you would any other source -- offer a citation in the text and identify them in your bibliography -- name, title, place, date -- and whether you communicated in person, or via telephone or email.
Your answer should be about 2000-2500 words (8-10 pages), and should be written in essay format. It will be due on Monday, March 23.

4. Test –The test will be based on the questions that will be "answered" in class and tutorials over the course of the term, roughly 4 per class x 11 classes. Ten of these questions will appear on the test, of which you will have to answer 2, each of which is worth 10 marks = 20% It will be held on the final class of the term, March 30.

Some Research Questions–I encourage you to engage the big questions about power, politics and health.

I am particularly interested in how corporate priorities are undermining the health of Canadians; and more specifically, how health policy is being shaped by corporate priorities; and how the delivery of health care is being affected by corporate needs.

In my article -- “Follow the Money: How Business and Politics Define Our Health,” in Social Determinants of Health: Canadian Perspectives, Second Edition, edited by Dennis Raphael – I examined how corporate priorities affect the social determinants of health at a relatively abstract structural level (in terms of the neo-liberal assault on the welfare state) and more concretely, how business influences our fiscal priorities (and it is at this macro-economic level that most of the damage is still being done).

We need to take a more detailed look at the specific mechanisms whereby these economic interests are able to affect public policy. The recent debate over health care reform in the US show just how dysfunctional that democracy has become in the face of corporate power. Canadians may gloat over the relative efficiency of our Parliamentary system and our public health care, but there has been an ongoing assault on public health in Canada via multiple mechanisms that undermine health outcomes in order to enhance corporate profits

It is important to identify all of these outrages against our public health. The battle is not being fought just in the corporate boardrooms and around the Cabinet table in Ottawa – they are battling for the hearts and minds of the Canadian public. If we are to convince the Canadian voters to support public health care we have to expose how corporate priorities are infecting our whole system at every level. For example:

  • How Big Pharma affects patents and drug prices, research funding, doctors prescribing practices, hospital hiring and firing;
  • How health insurance and workers compensation schemes affect our legal system, how they are trying to intimidate doctors;
  • How diagnostic testing has been privatized or contracted out;
  • How vitamins are being pushed to an unwitting public;
  • How private ownership of clinics, especially by doctors, threatens the values that underlie our system.

Once we’ve demonstrated the high degree of corporate influence, and their impact on the system, past, present and future, the next challenge will be to convince the public that they can influence change. We can chronicle concrete examples of political education and democratic influence, and get students "learning by doing".

RECOMMENED READINGS

Recommended – on Politics and the Canadian Political System

Brodie, Janine and Sandra Rein. (2008) Critical Concepts: An Introduction to Politics. 4th edition. Toronto: Prentice Hall.

Brodie, Janine and Linda Trimble (eds) (2003).Reinventing Canada: Politics of the 21st Century.Toronto: Prentice Hall.

Recommended – on Public Policy in Canada

Miljan, Lydia (2008). Public Policy in Canada: An Introduction, 5th ed. Toronto: Oxford.

Dobuzinskis, Laurent, Michael Howlett and David Laycock. (2007) Policy Analysis in Canada: The State of the Art. Toronto: University of Toronto Press.

Howlett, Michael, M. Ramesh and Anthony Perl (2009) Studying Public Policy

Policy Cycles and Policy Subsystems, Third Edition. Toronto: Oxford University Press.

Recommended – on Health Policy

Armstrong, Pat & Hugh (2008) Health Care. Halifax: Fernwood.

ISBN 13:978-1-55266-246-5

Armstrong, Pat and Hugh Armstrong. (2003) Wasting Away: The Undermining of CanadianHealth Care. 2nd edition. Toronto: Oxford University Press.

Armstrong, P., Armstrong, H. and Coburn, D. (eds.). (2001). Unhealthy Times; PoliticalEconomy Perspectives on Health and Care in Canada. Toronto: Oxford University Press.

Barlow, Maude. (2002) Profit is Not the Cure: A Citizen’s Guide to Saving Medicare. Toronto: McClelland and Stewart.

Beach, Charles, Richard Chaykowski, Sam Shortt, France St-Hilaire, and Arthur Sweetman (eds). Health Services Restructuring in Canada. Montreal and Kingston: McGill – Queen’s University Press.

Blake, Raymond and Jeffery Kesler (eds). (2006) Social Policy or Patchwork Quilt: The Development of Social Policy in Canada. Peterborough: Broadview.

Burke, Mike and Susan Silver. “Universal Health Care: Current Challenges to Normative Legacies” in Anne Westhues (ed). (2006)Canadian Social Policy: Issues and Perspectives, 4th edition.

Chappell, Neena L. and Margaret J. Penning. Understanding Health, Health Care, and Health Policy In Canada: Sociological Perspectives. Toronto: Oxford University Press, 2009.

Clavier, Carole and andEvelyne de Leeuw (eds.) (2013) Health Promotion and the Policy Process. London: Oxford.

Commission on the Future of Health Care in Canada. Building on Values: The Future of Health Care in Canada – Final Report. Commissioner: Roy J. Romanow.

Doern, Bruce (ed). (2006) How Ottawa Spends, 2006-2007: In from the Cold - the Tory Rise and the Liberal Demise. Montreal and Kingston: McGill-Queen's University Press.

Duckett, Stephen and Adrian Peetoom.(2013) Canadian Medicare. Montreal & Kingston: McGill-Queens.

Forest, Pierre-Gerlier, Gregory P. Marchildon and Tom McIntosh. (2004) The Romanow Papers – a three volume set. Toronto: University of Toronto Press.

Gustafson, Diana L. (2000) Care and Consequences: The Impact of Health Care Reform. Halifax: Fernwood,

Grieshaber-Otto, J. & Sinclair, S. (2004) Bad Medicine: Trade Treaties, Privatization and Health Care Reform in Canada. Ottawa: CCPA.

Health Council of Canada. (2010) Stepping It Up: Moving the Focus from Health Care in Canada to a Healthier Canada. Toronto.

Houston, Stuart and Merle Massie. (2013) 36 Steps on the Road to Medicare: How Saskatchewan led the way. Montreal & Kingston: McGill-Queens.

Johnson Redden, Candace. (2002) Health Care, Entitlement and Citizenship. Toronto: University of Toronto Press.

National Forum on Health. (1997). Canadian Health Action: Building on the Legacy: Volume II – synthesis reports and issue papers

Rachlis, Michael. (2004) Prescription for Excellence:How Innovation is Saving Canada's Health Care System. Toronto: Harper Collins. Available for downloading at

Panitch, Leo and Colin Leys. (2009) Morbid Symptoms: Health under capitalism. Socialist Register 2010. Halifax: Fernwood.

Raphael, Dennis. (2008) Social Determinants of Health: Canadian Perspectives. 2nd Edition. Toronto:Canadian Scholars Press.