DEVOLVING AUTHORITY FOR HEALTH-CARE IN CANADA PROVINCES .4. EMERGING ISSUES AND PROSPECTS

DEVOLUTION OF AUTHORITY FOR HEALTH CARE is evaluated in the context of 3 objectives of provincial governments - community empowerment to gar ner new allies for health care restructuring, service integration to c reate a true ''system'' and conflict containment as spending is cut. D evolved authorities cannot pursue each of these objectives with equal vigour because they must balance the competing pressures from their pr ovincial government, their providers and their local citizens. Each de volved authority accommodates these pressures in its own way, through different trade-offs. Appointed board members are generally well inten tioned in representing the interests of their entire community but are unlikely to overcome formidable barriers to community empowerment in health care. Unless future board elections attract large and represent ative voter turnouts, they may fragment board members' accountability (by making them more accountable to multiple interest groups) rather t han solidify it (by making them more accountable to the community). Al though boards have integrated and rationalized parts of the institutio nal sector, integration of the community sector is hampered by structu ral constraints such as the lack of budgetary authority for a broader scope of services, including physicians' fees and drugs. Devolved auth orities will deflect blame from provincial governments and contain con flict only while they believe that there is still slack in the system and that efficiency can be improved. When boards no longer perceive th is, they are likely to add their voices to local discontent with fisca l retrenchment. Continuing evaluation and periodic meetings of authori ties to share experiences and encourage cross-jurisdictional policy le arning are needed.