Health Studies Program hst 211 H1S – Health Policy in Canada

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Health Studies Program

HST 211 H1S – Health Policy in Canada


Winter 2017


Instructor: David Langille 647 280 7747

Office Location: B201 Office Hours: Monday, 11-12am or by appointment

Teaching Assistants: Ghazal Fazli

Sarah Sutherland


Health Studies Director: Sarah Wakefield

Health Studies Program Assistant: Khamla Sengthavy



This course introduces students to health policy in Canada, with a particular focus on the social determinants of health, and on how to improve health through policy advocacy. It examines the policy making process in the Canadian context, the development of health policy in Canada, and current debates about health issues .
Health is increasingly contentious with Canada’s aging population, advancements in medical technology, and government fiscal restraints. It is a challenge to achieve the best health given the limited resources available, and to ensure that health care is fair, equal, and accessible. The course will provide analytical tools for understanding health policy, offer an overview of current policy issues, and explore their relationship to social inequality, gender, and race.


The course will cover: 1) the policymaking process in general and in the Canadian context; 2) the Canadian health system and its development; 3) current health reform debates and issues, and 4) how to advocate for improvements in health policy.


Through readings and classroom discussions, the course will provide students with the knowledge skills to:

1) appreciate the social, political, and economic dimensions of health policy and policymaking;

2) critically analyse and evaluate current health policies in Canada;

3) consider emergent issues in Canadian health policy and current health reform issues;

4) build on students’ experience and skills in policy decision-making and advocacy.


Classes will be held Mondays 2-5 pm in UC161. Each three hour class will:

1) offer an analytic framework to understand health policy,

2) illustrate with examples of specific policy initiatives or policy gaps, and
3) discuss how to advocate to improve health policies 


Bryant, Toba (2016). Health Policy in Canada, Second Edition. Toronto: Canadian Scholars Press. ISBN 9781551303499
Fierlbeck, Katherine (2011). Health Care in Canada: A Citizen's Guide to Policy and Politics. Toronto: University of Toronto Press. ISBN 9781442609839
Laverack, Glenn (2013). Health Activism: Foundations and Strategies. Sage: London. ISBN 9781446249659
Recommended text:

Meili, Ryan (2012). A Healthy Society: How a Focus On Health Can Revive Canadian Democracy. Saskatoon: Purich. ISBN: 978-1895830-637

Lavis, John N. (2016). Ontario's Health System: Key Insights for Engaged Citizens, Professionals and Policymakers. Hamilton: McMaster Health Forum. (Individual book chapters are freely available on the McMaster Health Forum website)
All of these books are available for 3-hour loan from the University College Library (Course Reserves). There are additional articles listed in the Course Outline and/or available from Blackboard.
Note - If you have not taken UNI209, please read by Mikkonen, Juha and Dennis Raphael (2010). Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management – which is available on the internet for free at


Our course has a Blackboard site which will be used to share Course Announcements, an updated Course Schedule and reading requirements, and further details about your assignments, particularly the Advocacy Projects. It also connects us with the Gradebook where you can submit assignments and receive feedback.


Details on each assignment are included below, including the due dates:

  1. Answers to Questions on the Readings – 5 x 10 = 50%

  2. Essay Option (in place of 3 answers) - Outline – 5% and Essay – 25%

  3. Advocacy Assignment – 30%

  4. Test on the last day of class (in lieu of an exam)- 20%

Total - 100%

  1. Answers to Questions on the Readings – These assignments encourage you to read your text each week and come to class prepared for a good discussion of the material.

You are asked to prepare written answers to 5 questions, each being worth 10% of your grade. 5 answers x 10% = 60% (You can answer up to 6 questions (max!) and we will count the top 5.) Your answers have to be 450 to 700 words (max!), and must be handed in when it is due. Submit the summaries on Blackboard before the class begins. We will not accept them being handed in late, as that defeats the purpose of this assignment, which is to encourage you to read your text and be prepared to discuss the content.

Your answers should thoroughly cover the content of the text, although you are welcome to go beyond the text to draw on other material and your own ideas. (Citations are only needed for outside material – not for your text book.) If your answer shows evidence that you have read the material you may earn 5/10, if you give a clear answer to the question you can earn 6/10 or 7/10, and if you can offer an outstanding summation of the material(s) you can earn an “A” or 8 or 9 or even 10. Here are some tips for writing these weekly summaries:

What does an ‘A’ assignment look like?


  • Answers all elements of the question.

  • Shows advanced understanding of the material and an ability to articulate this understanding clearly and succinctly.

  • Uses own words to explain the concepts from the text. This is particularly critical when providing definitions - the more you are able to use your own words rather than relying on quotes, the more obvious it is that you understand the concepts.

  • Provides a context for the discussion.

  • Integrates your learning from previous weeks and show a developing understanding of the field of health policy.

  • Expresses some unique thoughts on the material or uses outside sources or examples to enhance the paper.  Always identify any personal opinion as such and provide justification for why you hold that opinion. Fully explain the examples that you raise and how they are relevant.


  • The summary is well structured with the use of paragraphs and a brief introduction and conclusion.

  • There is a clear and logical flow with good transitions between ideas.

  • Minimal grammatical / spelling errors and appropriate academic writing style.

  1. Essay Option - You have the chance to explore an area of your own interest in an essay rather than answer three of the smaller assignments.

You will be required to submit an outline and annotated bibliography beforehand, worth 5%. It will be due in class on Feb 13th. The outline should include a 150 word description of your topic and how you will approach it, and identify and describe at least 5 sources of material, with a couple of sentences to make clear why each source is relevant or useful for your paper. The essay itself will be due on March 20th, and is worth 25%. It should be 2500-3500 words, or roughly 10-15 pages double-spaced.

3. Advocacy Assignment – The Health Advocacy Project calls on you to resist the siren call of science. There are those who study public policy as a science, but they are largely irrelevant to the public policy debates that actually determine public policy. Sadly, public policy is not determined by rational scientific methods, nor by imitating best practices from around the world, but by the naked exercise of power, often in the pursuit of profit. Therefore, our best hope as citizens and students of health policy is that we are able to mobilize our democratic power and act collectively to control state institutions in the public interest -- to make them instrument of popular rule.
If you accept this premise, you need the skills to become political activists and community organizers, rather than be high priests of public policy. That's the best way to improve the social determinants of health – to seek excellence in citizenship, in public service and collective action. 
The assignments vary from year to year depending on the political timetable and the policy agenda. Students have options for either individual or group projects.
Advocacy Assignment Proposal -- Whichever of the options you chose below, you need to get started early in the term. Please submit a one page proposal that clarifies which option you have chosen, the specific topic you are addressing, who you are working with, your own role or goal and those of your group members (if you are working with a group). This proposal is worth 5% of your grade, and is due in class (on paper) on January 23. (Late submissions can be sent to your instructor electronically but will be deducted ½ of a percentage point per day.)


Group Project – Personal Journal -- If you work on a group project we need some objective criteria to assess how much you contributed to your project and what you learned in the process. Please present us with a journal that offers:

  • A summary description of what your group accomplished (150 words) – you are welcome to cut and paste from any documents you generated.

  • What you did for the project, step by step, i.e. time spent organizing, writing, researching, contacting people.

  • A critical assessment of what you and your group accomplished or did not accomplish (at least 150 words)

  • What you learned from participating in the project (150 words).

Your report should be roughly 4 pages (1000 words) plus appendices if necessary or appropriate. It need not be formally written. It will be due on Monday, March 27th.


Alternatively, you can work individually or in groups to survey the health policy community in Ontario, i.e. to investigate one of the many interest groups or organizations that is trying to shape health policy in this province in order to know their policy priorities, their power base, their communication methods and the overall effectiveness.
In this case, you have two options:

1. Choose one of the social determinants of health, and identify the policy community involved ie, describe the key actors and groups of actors who make policy decisions in this area eg, the government agencies, elected officials, corporations, non-governmental organizations, academic experts and policy consultants.  List them, and where possible, write a few sentences to describe them.    You are encouraged to assess the balance of forces, ie. which actors wield the most influence, and why do they have more influence than others?

2. Compare and contrast two organizations involved in health policy in Ontario in order to determine which wields the most influence, and why does it have more influence than the other.  These could be organizations working on the same issue or from widely different areas of the policy community.  You will have to:
a) Describe the organizations - in terms of the number of employees, their annual budget, who they represent, their goals, objectives and main activities.
b) Find out what policies they advocate and how they do so.  Were they active in the last election, and if so, how?
c) How do they communicate their positions, before and after the election eg. are they meeting with the Premier, the Minister of Health, the opposition leaders or their health critics,  or with their local candidates.  What print materials have they produced? What materials are they sending to their members, or to the media? What use are they making of their website or other social media? Offer some analysis of the material that you gather.


Whether you chose Option 1 or Option 2, be as concrete and specific as possible in your analysis of who has the most power and why.  This may require you to speak with actors in the policy community -- it will be difficult to find all the answers in the library or on the internet.  Treat such interviews as you would any other source -- offer a citation in the text and identify them in your bibliography -- name, title, place, date -- and whether you communicated in person, or via telephone or email. 

Your answer should be about 2000-2500 words (8-10 pages), and should be written in essay format. It will be due on Monday, March 27th.


4. Test – The test will be based on the questions that will be "answered" in class and tutorials over the course of the term, roughly 4 per class x 11 classes. You will be given 10 questions one week before the test – five of these questions will appear on the test, of which you will have to answer 2, each of which is worth 10 marks = 20% You will have two hours, and it will be held on Monday, April 3rd.


Contacting the Instructor or TAs

You can reach your Instructor in person during his office hours (or at other times by appointment); or via email; all email communications should be brief and courteous. Please do not expect an immediate reply to your email, but every effort will be made to get back to you within 48 hours (weekends not included). The TAs will normally be available during the final hour of class. Students will receive course communications through their email address - students should check their utoronto email regularly.

Assignment Submission and Late Penalties

Your responses to the Weekly Reading Assignments must be uploaded on BOTH the course website and the website before class on the day the assignment is due. Given that you only have to answer 5 questions during the term, we will be strict about this. (If you chose the Essay Option then you must submit an outline and annotated bibliography on paper in class on Feb 13th.

The Advocacy Assignment Proposal is due in class (on paper) on January 23. (Late submissions can be sent to your instructor electronically but will be deducted ½ of a percentage point per day.) If you do a Group Project your Personal Journal will be due in class on Monday, March 27th. (Otherwise your Advocacy Essay is due in class on Monday, March 27th.) If they Journal or the Essay are late they can be sent to your instructor electronically but will be deducted ½ of a percentage point per day.)

Be sure to retain a copy of your papers and keep all your notes and drafts.

Extensions and Accommodations

Extensions will be granted in the case of illness or other emergencies, with appropriate documentation (see for more information). Please consult your college registrar if you have ongoing difficulties during term – health related or otherwise – that prevent you from completing your course work satisfactorily. If you require accommodation for a disability or long-term illness, or have any accessibility concerns about the course, the classroom or course materials, please contact Accessibility Services as soon as possible at

Academic Integrity

Academic integrity is fundamental to learning and scholarship at the University of Toronto. At the University of Toronto, the following things are considered academic offences in papers you write:

  • Using someone else’s ideas without appropriate acknowledgement (i.e., in-text citation)

  • Copying material directly from a source and not placing the words within quotation marks

  • Submitting your own work in more than one course without the permission of the instructor

  • Making up sources or facts, or including references to sources that you did not use.

  • Obtaining or providing unauthorized assistance on any assignment including:

  • Having someone else complete part or all of an assignment for you

  • Working in groups on assignments that are supposed to be individual work

  • Having someone rewrite or add material to your work while editing (having someone read your work is a good idea, but they should tell you what is wrong, not fix it for you)

  • Lending your work to a classmate who submits it as his/her own

The University of Toronto treats cases of academic misconduct very seriously. All suspected cases of academic dishonesty will be investigated following the procedures outlined in the Code. The consequences for academic misconduct can be severe, including a failure in the course and a notation on your transcript. If you have any questions about what is or is not permitted in this course, please do not hesitate to contact the course instructor, the TA, other available campus resources like the U of T Writing Website. More information is available at

Normally, students will be required to submit their work to for review of textual similarity and detection of possible plagiarism. This will allow their work to be included as source documents in the reference database, where they will be used solely for the purpose of detecting plagiarism. The terms that apply to the University’s use of the service are described on the website. Using Turnitin is optional, it is not mandatory.

I encourage you to engage the big questions about power, politics and health.
I am particularly interested in how corporate priorities are undermining the health of Canadians; and more specifically, how health policy is being shaped by corporate priorities; and how the delivery of health care is being affected by corporate needs.
In my article -- “Follow the Money: How Business and Politics Define Our Health,” in Social Determinants of Health: Canadian Perspectives, Third Edition, edited by Dennis Raphael – I examined how corporate priorities affect the social determinants of health at a relatively abstract structural level (in terms of the neo-liberal assault on the welfare state) and more concretely, how business influences our fiscal priorities (and it is at this macro-economic level that most of the damage is still being done).
We need to take a more detailed look at the specific mechanisms whereby these economic interests are able to affect public policy. The recent debate over health care reform in the US show just how dysfunctional that democracy has become in the face of corporate power. Canadians may gloat over the relative efficiency of our Parliamentary system and our public health care, but there has been an ongoing assault on public health in Canada via multiple mechanisms that undermine health outcomes in order to enhance corporate profits
It is important to identify all of these outrages against our public health. The battle is not being fought just in the corporate boardrooms and around the Cabinet table in Ottawa – they are battling for the hearts and minds of the Canadian public. If we are to convince the Canadian voters to support public health care we have to expose how corporate priorities are infecting our whole system at every level.  For example:

  • How Big Pharma affects patents and drug prices, research funding, doctors prescribing practices, hospital hiring and firing;

  • How health insurance and workers compensation schemes affect our legal system, how they are trying to intimidate doctors;

  • How diagnostic testing has been privatized or contracted out;

  • How vitamins are being pushed to an unwitting public;

  • How private ownership of clinics, especially by doctors, threatens the values that underlie our system.

Once we’ve demonstrated the high degree of corporate influence, and their impact on the system, past, present and future, the next challenge will be to convince the public that they can influence change. We can chronicle concrete examples of political education and democratic influence, and get students "learning by doing".


Recommended – on Politics and the Canadian Political System
Brodie, Janine and Sandra Rein. (2008) Critical Concepts: An Introduction to Politics. 4th edition. Toronto: Prentice Hall.
Recommended – on Public Policy in Canada
Miljan, Lydia (2008). Public Policy in Canada: An Introduction, 5th ed. Toronto: Oxford.
Dobuzinskis, Laurent, Michael Howlett and David Laycock. (2007) Policy Analysis in Canada: The State of the Art. Toronto: University of Toronto Press.
Howlett, Michael, M. Ramesh and Anthony Perl (2009) Studying Public Policy

Policy Cycles and Policy Subsystems, Third Edition. Toronto: Oxford University Press.
Recommended – on Health Policy
Armstrong, Pat & Hugh (2008) Health Care. Halifax: Fernwood.

ISBN 13:978-1-55266-246-5

Armstrong, Pat and Hugh Armstrong. (2003) Wasting Away: The Undermining of Canadian Health Care. 2nd edition. Toronto: Oxford University Press.
Armstrong, P., Armstrong, H. and Coburn, D. (eds.). (2001). Unhealthy Times; Political Economy Perspectives on Health and Care in Canada. Toronto: Oxford University Press.
Barlow, Maude. (2002) Profit is Not the Cure: A Citizen’s Guide to Saving Medicare. Toronto: McClelland and Stewart.
Beach, Charles, Richard Chaykowski, Sam Shortt, France St-Hilaire, and Arthur Sweetman (eds). Health Services Restructuring in Canada. Montreal and Kingston: McGill – Queen’s University Press.
Blake, Raymond and Jeffery Kesler (eds). (2006) Social Policy or Patchwork Quilt: The Development of Social Policy in Canada. Peterborough: Broadview.
Burke, Mike and Susan Silver. “Universal Health Care: Current Challenges to Normative Legacies” in Anne Westhues (ed). (2006) Canadian Social Policy: Issues and Perspectives, 4th edition.
Chappell, Neena L. and Margaret J. Penning. Understanding Health, Health Care, and Health Policy In Canada: Sociological Perspectives. Toronto: Oxford University Press, 2009.
Clavier, Carole and and Evelyne de Leeuw (eds.) (2013) Health Promotion and the Policy Process. London: Oxford.
Commission on the Future of Health Care in Canada. Building on Values: The Future of Health Care in Canada – Final Report. Commissioner: Roy J. Romanow.

Doern, Bruce (ed). (2006) How Ottawa Spends, 2006-2007: In from the Cold - the Tory Rise and the Liberal Demise. Montreal and Kingston: McGill-Queen's University Press.

Duckett, Stephen and Adrian Peetoom.(2013) Canadian Medicare. Montreal & Kingston: McGill-Queens.

Forest, Pierre-Gerlier, Gregory P. Marchildon and Tom McIntosh. (2004) The Romanow Papers – a three volume set. Toronto: University of Toronto Press.
Gustafson, Diana L. (2000) Care and Consequences: The Impact of Health Care Reform. Halifax: Fernwood,
Grieshaber-Otto, J. & Sinclair, S. (2004) Bad Medicine: Trade Treaties, Privatization and Health Care Reform in Canada. Ottawa: CCPA.

Health Council of Canada. (2010) Stepping It Up: Moving the Focus from Health Care in Canada to a Healthier Canada. Toronto.

Houston, Stuart and Merle Massie. (2013) 36 Steps on the Road to Medicare: How Saskatchewan led the way. Montreal & Kingston: McGill-Queens.

Johnson Redden, Candace. (2002) Health Care, Entitlement and Citizenship. Toronto: University of Toronto Press.
National Forum on Health. (1997). Canadian Health Action: Building on the Legacy: Volume II – synthesis reports and issue papers­_forum/
Rachlis, Michael. (2004) Prescription for Excellence: How Innovation is Saving Canada's Health Care System. Toronto: Harper Collins. Available for downloading at
Panitch, Leo and Colin Leys. (2009)  Morbid Symptoms: Health under capitalism. Socialist Register 2010. Halifax: Fernwood.
Raphael, Dennis. (2008) Social Determinants of Health: Canadian Perspectives. 2nd Edition. Toronto: Canadian Scholars Press.
Raphael, Dennis. (2007) Poverty and Policy in Canada: Implications for Health and Quality of Life. Toronto: Canadian Scholars Press.
Raphael, Dennis, Toba Bryant and Marcia Rioux. eds. (2006) Staying Alive: Critical Perspectives on Health, Illness, and Health Care. Toronto: Canadian Scholars Press.
Sullivan, T. Baranek, P.N. (2002). First Do No Harm: Making Sense of Canadian Health Reform. Vancouver: UBC Press.
Walt, Gillian. (1994) Health Policy: Politics and Processes. London: Zed.
On Health Advocacy:
Laverack, Glenn. (2013) Health activism: foundations and strategies. London: Sage 2013.
Other sources of material:
CHSRF Myth Busters are available at e.php .

University of Toronto – University College – Health Studies

HST 211H1F - Introduction to Health Policy - Winter 2016

(Subject to revision to accommodate our guest speakers)

Lecture Topic and Required Readings
January 9 Introduction to the Course & Introductions of the Class

Film – Sicko, by Michael Moore

January 16 Introduction to Politics and Public Policy
Read: Brodie, Janine and Sandra Rein. (2008) Critical Concepts: An Introduction to Politics. 4th ed. Everyone should skim Chapter 1 and 2. You are encouraged to read at least one other chapter….either Ch 3 on the Liberalism (the mainstream ideology in Canada), Ch 4 on Democracy (the ideals that undermine our system), or Ch 5 on Radical Politics (seeking a better world, in our lifetime). You are welcome to consult other sources for this assignment, eg. Encyclopedia Britannica.
January 23 Health Policy and Policy Studies

Read: Bryant, Ch 1 and 2

And read: Laverack, Glenn (2013) Health Activism: Foundations and Strategies. Ch. 1 – Foundations of Health Activism

January 30 Theories of Public Policy and Policy Change
Read Bryant chs 3 and 4

and Laverack, Chapter 4 - Strategies to influence healthy public policy

February 6 Influencing Policy - from the Outside
Read Bryant ch 5

and Langille ch 20 from Raphael’s, Social Determinants of Health in Canada (on Blackboard)

Also see Bryant Ch 11 on “Globalization and Free Trade”
February 13 Health Care in Canada
Read Bryant ch 6

Read Michael Rachlis, “Canadians are ready for an adult conversation on Medicare” Originally published in the Toronto Star, Oct 14, 2012. Revised Dec 5, 2013
February 22 READING WEEK

February 27 Reform of Health Care

Read Bryant ch 7 and Fierlbeck ch 1

March 6 Private vs Public – Is there a role for the market?

Read Bryant ch 8

Read Sutherland, Medical Laboratories and the Public-Private Debate, Introduction to False positive: private profit in Canada's health care, Halifax:Fernwood, 2011

Read Fierlbeck ch 9

March 13 An International Perspective on Health Policy
With guest Dennis Raphael, Professor of Health Policy and Management, York U and author of Tackling health inequalities: Lessons from International experiences; Poverty in Canada: Implications for health and quality of life; Social determinants of health: Canadian perspectives, etc….

Read Bryant ch 9

Recommended: Fierlbeck ch 10, 11
March 20 Drugs and Drug Policy

Read Fierlbeck ch 7

Also see - Tang, Ghali and Manns, Addressing cost-related barriers to prescription drug use in Canada , CMAJ, March 4, 2014, 186 (4).

March 27 Mental Health Policy

Read Fierlbeck ch 8

Read Mental Health Commission of Canada, Changing Directions, Changing Lives

Read Mental Health Commission of Canada, Making the Case for Investing in Mental Health in Canada

Read Ontario Ministry of Health and Long Term Care, “Open Minds, Healthy Minds: Ontario’s Comprehensive Mental Health and Addictions Strategy”

April 3 Test

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