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In many developed nations, the legitimacy of the state’s role in public policy implementation is increasingly being questioned. That a recent issue of Public Administration was devoted to the topic illustrates the scope and relevance of these concerns (see Barrett 2004; Exworthy and Powell 2004; O’Toole 2004; Schofield 2004). Explanations of the problems afflicting policy implementation have long focused on the approach adopted – i.e., top-down (Sarbaugh-Thompson and Zald 1979) or bottom-up (Berman 1978; Hjern et al. 1978). Proponents of the top-down approach address control and communication among hierarchical levels. Supporters of the bottom-up approach, however, consider the political micro-processes at play among stakeholders that have different interests and, often, irreconcilable values. In their view, the implementation of public policy results from negotiation (Strauss 1978) that depends on the structure of the network of stakeholders, their interaction and the distribution of power among them. Most recent research (e.g., O’Toole 2000; Meier et al. 2004) devoted to public policy analysis places greater emphasis on the question of governance, understood in the broadest sense as the organization of collective action (Prakash and Hart 1999). Governance is concerned more with strategic issues than with management. It centres on a continuous process of interaction and negotiation among stakeholders at multiple levels. To govern is to adopt common representations, structures, rules and performance indicators with a view to coordinating stakeholders so that power can be exercised in a pluralistic manner. Taking a governance perspective makes it possible to go beyond the top-down versus bottom-up debate because it accounts for both process and the distributed nature of collective action. Because governance emphasizes that a number of stakeholders who do not necessarily share the same interests can – and often do – participate in managing public affairs, the concept makes it possible to link various levels of analysis concerning the role of the community, civil society, private enterprise, local and regional government and the state (Daly 2003). In this paper, we focus on governance and the added value of regionalization in the context of health policy implementation. In most Canadian provinces, regionalization – the establishment of an intermediate governing structure at the regional level that assumes functions previously fulfilled by a central or local government (Lewis and Kouri 2004) – has been aimed at reinforcing governance capacity. Ambitions have been high: redefining accountability rules, democratizing decision-making, enhancing responsiveness to public needs, increasing the fairness of resource distribution among regions, developing a more comprehensive approach to health problems, using resources more efficiently and improving continuity of care. Opinions on the effectiveness of regionalization are, however, divided (Church and Barker 1998; Davis 2004; Levine 2004; Sullivan et al. 2004). Even if some progress has been made (Gosselin 1984; Lewis and Kouri 2004; Denis et al. 2004), regionalization’s full potential has not been realized (Church and Barker 1998; Lamarche 1996; Lewis 1997; Hurley 2004; Lewis and Kouri 2004). Our objective here is not to offer an opinion on the potential of regionalization but to generate a more thorough understanding of the role regionalization plays in health policy implementation. We carry this out by exploring two main questions: What are regional boards’ patterns of action in the governance process? How do these patterns favour policy implementation? In order to answer these questions, we take the Programme de lutte contre le cancer (PLC) (Program to Combat Cancer) adopted by Quebec’s Ministry of Health and Social Services in 1998 (Ministere de la sante et services sociaux 1997) as a good illustration of regionalization’s potential to be an effective governance tool. We begin our discussion by clarifying the form regionalization has taken in Quebec and the objectives and means PLC adopted. Next, we describe our analytical framework and methodology. We then present and analyze our findings based on an evaluation of PLC’s implementation in the Monteregie region (Roberge et al. 2004). Our paper ends with a general consideration of regionalization and the threats it faces. |
