Community action success in public health: are we using a ruler to measure a sphere?

The Community Action and Public Health study explored how Ontario public health practitioners interpret and implement guidance in community action. In-depth interviews were conducted with 107 public health professionals and community members in 6 Ontario health units. This report briefly describes the study methods and presents results pertaining to the measurement of success based on interviews with 67 public health professionals. Data substantiate the view that evaluation methodologies employing quantitative measures of epidemiological outcomes inadequately capture "success" in community action, possibly attributable to an unproductive dichotomization of "process" and "outcome". Results suggest two kinds of "success": a) changes related to stated goals and targets; and b) more iterative and process-oriented changes, including necessary but often undocumented shifts in relationships, structures, social conditions and processes. In order to legitimize and validate results that might otherwise pass unrecognized, we suggest a methodology that records project "milestones" as successes in their own right.

Universal access in Canada. Questions of equity remain.

Health/PAC readers will remember Samuel Wolfe's previous Bulletin article about Canada's national health care system ("Importing Health Care Reform? Issues in Transposing Canada's Health Care System to the United States," Summer 1990), in which he described the uniqueness of our northern neighbor's experience. At that time, Wolfe expressed doubt that a Canadian-like model could find sufficient political and social momentum to be propelled south. In this latest article, Wolfe is joined by his long-time colleague, Robin Badgley, to discuss the inequity and inequality they believe still exists within the Canadian system. Wolfe and Badgley's insightful analysis of what they see as shortcomings of the Canadian model and suggestions for their remedy are especially welcome given the questionable validity of most criticism of the Canadian system that Americans hear. Their work helps us understand the real problems that remain in the still-evolving Canadian system. As Americans discuss the various possibilities for progressive single-payer reform, many envision of state-based system. Wolfe and Badgley point out that demographically rooted inequalities and the lingering health burdens of social class may interfere with truly national universal access. They also alert us to the dangers that federal retreat from adequate levels of support would pose to such a state strategy. Samuel Wolfe has a unique background as a country doctor, psychiatrist, and public health official who attended the difficult birth of Saskatchewan's provincial health plan--the prototype for Canada's national health insurance. A respected teacher, researcher, and community health activist, Wolfe has taught in the United States for more than 25 years. He will soon move back to Canada and the welcome security of its universal health care system.

Social and economic disparities under Canadian health care.

Central to the objectives of Canadian national health insurance were the principles that health is a basic right that should be open to all and that all Canadians, regardless of their ability to pay, would be provided with publicly financed comprehensive hospital and medical services. During the two decades that this program has been in place, substantial gains have been realized in making insured services more accessible to all Canadians, in the reduction of regional mortality disparities, and in a leveling out of earlier sharp differences in the supply of health resources across Canada. These changes have not been matched by any significant realignment of the health status of Canadians relative to their economic circumstances, nor as yet by the full removal of economic constraints affecting accessibility to health services. The Canadian experience raises the fundamental concern of whether a reasonable level of equity can be achieved in nations having distinctive regional priorities, a federal structure linking people of different cultural identities, and where a sharp gradient of economic opportunities is entrenched.

Health worker strikes: social and economic bases of conflict.

Entrenched social and economic inequities combined with spiralling inflation have led to a growing number of health worker strikes. The bases of conflict, as yet unresolved, challenge the caste-like structure of health systems. By highlighting the need for change, health worker strikes may foster an internal dynamism and the more democratic organization of working conditions in health services.