Understanding the role of contextual influences on local health-care decision making: case study results from Ontario, Canada

Abstract

Approaches to involving the public in local health care decision making processes (and analyses of these approaches) have tended to treat participation and publics uniformly in search of the ideal method of involving the public or providing the same opportunities for public participation regardless of differing socio-economic, cultural, insitutional or political contexts within which decisions are made. Less attention has been given to the potential for various contextual factors to influence both the methods employed and the outcomes of such community decision-making processes. The paper explores the role that context (three sets of contextual influences more specifically) plays in shaping community decision-making processes. Results from case studies of public participation in local health-care decision making in four geographic communities in Ontario are presented. During the study period, two of these communities were actively involved in health services restructuring processes while one had recently completed its process and the fourth had not yet engaged in one. Several themes emerge from the case studies regarding the identification and role of contextual influences in differentially shaping participation in local health care decision-making. These include the propensity for communities with different social and structural attributes to engage in different “styles” of participation; the importance attached to “community values” in shaping both the qualitative and quantitative aspects of participation; the role of health councils, local government and inter-organizational collaboration as participation “enablers”; and the politicization of participation that occurs around contentious issues such as hospital closures.

Introduction

For centuries, participation analysts and advocates have debated the merits and deficiencies of different methods for involving citizens in the decisions affecting them. Inextricably linked to the democratic principles of ‘government for the people, by the people’ is the involvement of the citizenry, either directly or indirectly, in government decisions. Democratic participation involves sharing power for government decision-making, and hence, discussions about how that power should be shared (i.e., among citizens, experts and elected officials). These issues are being actively debated among policy-makers and researchers in the health care domain where questions of who should be involved, in what decisions, how, and in what capacity, are at the forefront of discussions pertaining to the allocation of resources within and across global budgets. That the public should be involved in these decisions is no longer under serious debate as decision-makers, faced with increasingly difficult resource allocation decisions, welcome the opportunity to share this task (and the associated blame) with the public. Choosing an appropriate combination of public, elected officials, experts and stakeholders to make these decisions, however, can be complicated and determining how and what public views will be obtained and incorporated in the decision-making process even more challenging. Much of the health services research that has been conducted in this area has focused on eliciting public preferences or priorities, often from a list of pre-determined programs or services. This input is frequently obtained using either a single consultation method for a particular group (e.g., citizen surveys, citizen panels, etc.) (Lenaghan, New, & Mitchell, 1996; Bowie, Richardson, & Sykes, 1995) or a single method across comparison groups (e.g., surveys of providers, administrators, patients) (Bowling, 1996; Myllykangas, Ryynanen, Kinnunen, & Takala, 1996). Other research has focussed on evaluating the merits and deficiencies of public and community consultation exercises within a specific service sector (e.g., long-term care reform, health services restructuring) (Aronson, 1993; Abelson & Lomas, 1996).

The research that falls into each of these broad categories has improved our understanding of the results obtained and challenges faced when trying to involve the public in health services decision making. However, approaches to involving the public in local health care decision-making processes (and subsequent analyses of these approaches) have tended to treat participation and publics uniformly in search of the ideal method of involving the public or providing the same opportunities for public participation regardless of the differing socio-economic, institutional or political contexts within which decisions are being made. Little attention has been given to the potential for various contextual factors to influence both the methods employed to involve the public and the outcomes of such community decision-making processes. The purpose of this paper is, therefore, to explore the role that context (three sets of contextual influences more specifically) plays in shaping community decision-making processes in the health services sector and to inform future research and practice in the area of public participation in health-care decision-making.