For my dissertation research I investigated the role of the market in health care reforms. In 1995, the Progressive Conservative government in the Canadian province of Ontario introduced a “managed competition” model as part of its wide ranging reform of home care.  This model assumed that competitive forces can encourage high quality services while driving down service costs.  Although health human resources constitute the largest component of such costs, there has been little analysis of the impact of managed competition on rehabilitation professionals, their professional autonomy, or the health care system as a whole. We analyze the results of two surveys and 36 in-depth interviews with representatives of Ontario’s publicly funded Community Care Access Centres (CCACs) as well as for-profit and not-for-profit rehabilitation provider agencies.  Professional autonomy has been conceptualized as consisting of the distinct but related dimensions of economic, political and clinical autonomy; measures were created for each of these dimensions. The findings demonstrate that Ontario’s managed competition reform led to an overall reduction in the economic, political and clinical autonomy of rehabilitation professionals.  This erosion was experienced equally by individuals working in for-profit and not-for-profit provider agencies,  prompting significant numbers of health professionals to exit home care, thus exacerbating existing health human resources shortages. While reducing the autonomy of health professionals may help to control health care costs, it may also have perverse outcomes from a health systems viewpoint.  These include difficulties with recruitment and retention of professionals as well as concerns about the quality of health services provided.  Findings suggest the need for a more nuanced approach to health care reforms.

Examples of Conference Presentations

CAHSPR conference (2004) – Limits to Market-Based Reform: Managed Competition and Rehabilitation Home Care Services in Ontario

Health Services & Research Policy Conference, Canberra, Australia (2005) – The Impact of Health Care Reform on Professional Autonomy

Related Publications

Randall, G.E., and Williams, A.P. (2009). Health care reform and the dimensions of professional autonomy. Canadian Public Administration / Administration Publique du Canada. 52(1): 51-69.

Randall, G.E. (2008). The impact of managed competition on diversity, innovation and creativity in the delivery of homecare services. Health and Social Care in the Community. 16(4): 347-353. PMID: 18613910.

Randall, G.E. (2007). The reform of home care services in Ontario: opportunity lost or lesson learned?  Canadian Journal of Occupational Therapy. 74(3): 209-217. PMID: 17616019.

Randall, G.E. (2007). Competition, organizational change and conflict: the changing role of case managers in Ontario’s homecare system. Care Management Journals. 8(1): 2-7. PMID: 17491444.

Randall, G.E. and Williams, A.P. (2006). Exploring limits to market-based reform: managed competition and rehabilitation home care services in Ontario. Social Science and Medicine. 62(7): 1594-1604. PMID: 16198035.