Multiple accountabilities in the Manitoba’s health-care system

Hey there, time traveller!
This article was published 24/08/2024 (641 days ago), so information in it may no longer be current.

I always read and learn from the articles in this space by Deveryn Ross when he reflects on his five years as a senior adviser to then-Conservative premier Brian Pallister. Even accepting that there can be a bias involved, his articles offer insider perspectives not available to an outsider like me.

Today I am reacting to his Aug. 6 article, Pain, suffering and provincial health-care problems, which asked the question: “Who really controls the health system?”

His answer was that, according to the principles of ministerial responsibility, the minister of health should be in charge, but in practice they have little actual control over the complex, sprawling, multi-tiered health-care system.

Instead, given the specialized knowledge required, the appointed permanent officials in various domains and on different levels have significant influence over policy formulation and actually control the delivery of services.

The article concludes that when there are policy blunders, mismanagement or preventable mistakes in the provision of health care, elected ministers are blamed and anonymous, appointed health personnel escape accountability.

One could not expect a 800-word article to describe the multi-faceted phenomenon of accountability within Manitoba’s health-care system. It would be wrong, however, to leave readers with the impression there is only one route to accountability based on the answerability of the minister of health to the premier and cabinet, the legislature, to the media, and ultimately to the public.

Over time, as dissatisfaction with ministerial responsibility as a basis for accountability grew, a range of supplementary accountability mechanisms were created. There are now at least six broad types of accountability: political, administrative/hierarchical, legal/professional, financial, results-based, and client/complaint based. Only a brief comment about the nature and significance of each type of accountability is possible in the space available here.

Ministers are appointed by the premier and are now expected to lead the department based on a published mandate letter which reflects the priorities of the government. Ministers steer the department and outside bodies, like Shared Health and the regional health authorities (RHAs), by remote control through legislation, policy directions, resource allocation, etc.. The minister lacks the specialized knowledge to make operational decisions. Recognition of these realities means that when things go seriously wrong, ministers seldom resign or are removed by the premier, instead they assume responsibility for fixing problems.

Administrative/hierarchical accountability operates throughout the health system. Within the department, the minister is supported by a deputy minister, usually a career public servant, who is expected to ensure the execution of government policies and runs the department on a daily basis. Similar principles of unified top-down direction, control and accountability are meant to operate within such semi-independent bodies like Shared Health, RHAs, hospitals and personal care homes. Combining autonomy to benefit from professional expertise with accountability for performance represents an ongoing challenge within the health field.

Financial accountability involves budgetary controls meant to ensure that there is economy, efficiency, effectiveness, and equity in health spending. Internal audits and external reviews by the office of the auditor general identify budgetary issues. Regionalization in the 1990s was meant to grant RHAs autonomy from centralized, departmental control over spending, but this did not happen. Provincial governments have imposed cutbacks, restraint and restrictions, but demands for health services always exceed available resources of all kinds. Complexity and blurred accountability are a permanent feature of health spending.

Legal/professional accountability operates in multiple health domains, only a few of which can be mentioned here. The Regulated Health Professional Act sets out the rules for the registration, complaints and discipline for over 20 health professions. There are codes of conduct and standards of practice for various health disciplines. Serious incidents in the health field legally undergo investigation and public reporting. Deaths in certain circumstances require a report from the chief medical examiner, who can also order a medical inquiry to be conducted.

Results-based accountability is meant to support steering of the health system. Premier Pallister was a strong believer in balanced scorecards as a mechanism to measure the impacts of programs and to hold the health bureaucracy accountable. The health department and other health entities were required to measure and report publicly on performance indicators which reflect the priorities of the government. “Dashboards” on health outcomes were posted online, unfortunately not always on a continuous basis.

Client accountability starts with patient-centred models of service provision in which patients cooperate with health professionals in the development of care plans. Physician profiles, which include educational backgrounds and any disciplinary decisions regarding doctors, are available on line. There are patient relations offices in most institutions. The office of the ombudsman deals with complaints involving parts of the health system and oversees freedom of information and privacy laws. Outside advocacy organizations promote the rights of patients and help them to navigate the complex health system.

Multiple accountabilities do not guarantee safe, quality, affordable, responsive and accountable healthcare policy and service delivery. Ultimately society must depend heavily on an internalized sense of responsibility (let’s call it “felt accountability “) which guides the behaviour of all the public officials from the health minister all the way out to the health-care aides on the front lines.

Paul G. Thomas is professor emeritus of political studies at the University of Manitoba.