LE SECTEUR BÉNÉVOLE DANS LE MONDE DE LA SANTÉ PUBLIQUE
vol. 41, numéro 4, 2011
Much discussion has taken place over the past few decades about the concept of network governance, and what it might mean for liberal democratic regimes. This notion, which goes by many other names, including collaborative governance (Ansell and Gash 2008), New Public Service (Denhardt and Denhardt 2002), Public Value Management (Stoker 2006) and inter-organizational innovations (Mandell and Steelman 2003), is well described as “…a spectrum of structures that involve two or more actors and may include participants from public, private, and nonprofit sectors with varying degrees of interdependence to accomplish goals that otherwise could not be accomplished independently” (Ibid.: 202). Several writers have seen network governance as instrumental in strengthening liberal democracy in modern times by establishing a broader base for inclusion in public policy issues (Stoker 2006; Denhardt and Denhardt 2002; Box et al. 2001). The argument is advanced that the level of complexity surrounding many public policy issues today is such that, in order for issues to be successfully resolved, mechanisms need to be established that allow for the active participation of all interested stake-holders. It follows, therefore, that civil society, positioned as it is “outside the reach of state bureaucracy and beyond the interests of the private sector” (Morison 2000: 105) has a key role to play in this notion of governance.
Few question that the voluntary sector plays a key role in public health. It is estimated that there are approximately 5,300 voluntary sector organizations (VSOs) that are involved in work in the health field in Canada (Imagine Canada 2007a). Unfortunately, no estimate is available of how many organizations are involved in the various dimensions of public health. Despite the centrality of the voluntary sector for public health in Canada, many knowledge gaps remain in this area. (Brock et al. 2007) While there is no precise estimate how many VSOs are directly involved in public health, given the breadth and diversity of the sector, it is safe to assume that the number is quite impressive. More than simply a question of numbers, however, is the role they play. Public health departments and agencies at the national, provincial and local levels often rely on VSOs to reach vulnerable clients at the community level. In addition, there exists a myriad of organizations playing an advocacy role on a full range of issues, including mental health, infectious diseases, chronic diseases and injury prevention. In this way, they provide a “window” into the interests and concerns of the community of interest. VSOs can also be repositories of considerable expertise, often playing a major role in research in such areas as heart disease, cancer and mental health.
The purpose of this article is to discuss the place of the voluntary sector in public health governance in Canada. We will begin with a brief overview of the voluntary sector in general, as well as its place in Canada, and more specifically in the national public health arena. Following this, a typology will be proposed of the various types of relationships between voluntary sector organizations in the public health sector with government at the national level, providing examples of each type of relationship for purposes of illustration. We will then conclude with a discussion of what the current configuration means for the prospects of network governance in the public health sector in Canada. Our general proposition is that while the voluntary sector has a key role to play in the governance of the public health area, much of this potential remains untapped, and that while there are a few recent examples which appear to “break the mould”, it is far from clear whether these should be seen as aberrations or as indications of new directions for the future.
The research in this paper is based on document review, as well as 20 semi-structured interviews with government officials and with representatives of VSOs involved in public health. To protect anonymity, these interviews, when cited, will be identified by a number and the date on which the interview in question was conducted.
The voluntary sector: terminology and context
A number of different terms can be found in the literature related to this sector, with overlapping but not identical meanings which can lead to a certain amount of terminological confusion. Civil society, non-governmental organizations, non-profit organizations, the “third” sector, philanthropic organizations and interest groups are all fairly common terms, but do not always carry the same meaning. Civil society is often understood to mean “the broad range of social institutions that occupy the social space between the market and the state” (Salamon et al. 1999: 3), but this can sometimes be understood to include both for-profit and not-for-profit organizations. In the same way, non-governmental organizations can also include both types of organizations. In this chapter, we will use the term “voluntary sector” which we take to mean all organizations led by boards, the members of which serve on a voluntary basis. This does not mean that these organizations are composed entirely of volunteers, as in many cases they have salaried personnel to carry out their activities. Moreover, these are organizations which operate on a not-for-profit basis for the purpose of achieving a public good. Finally, they are understood to be formally independent from government, even though, as will be discussed, they may work quite closely with government, or may indeed receive a significant portion (if not all) of their funding from government.1 Using “voluntary sector” rather than non-profit or not-for-profit has the added advantage, as has been pointed out, of avoiding describing the sector in the negative, that is, as not being something else (Phillips 2001: 259 fn. 3.).
The importance of the voluntary sector is not new in liberal democracies. Indeed, de Tocqueville attached a great deal of importance to this sector as a “necessary guarantee against the tyranny of the majority” (de Tocqueville, 1945: 201-02). Freedom of association also features prominently in the First Amendment of the US Constitution, which is sometimes referred to as the Magna Carta of the voluntary sector in that country. More recently, it has been quite common in US literature to cite the importance of the “Iron Triangle” in public decision-making: the three points of the triangle being congressional committees, the bureaucracy and “interest groups” (Pross 1986: 97).
Since the 1960s, the role of the voluntary sector, consistent with the notion of modern governance, has undergone a fairly significant transformation. A. Paul Pross observed that the diffusion of power in modern society “has transformed participating interest groups from useful adjuncts of agencies into vitally important allies” (Ibid.: 243). Indeed, VSOs are now often the delivery agents for government programs and services, and are increasingly finding a place in the development of research and public policy (Brock 2001: 263; Juillet et al. 2001: 25). The increasing importance of the voluntary sector is evidenced in the fact that in the late 1990s, both the UK and Canada produced major reports on the role of the voluntary sector, followed by “compacts” (in the case of England and Scotland) and an accord (in the case of Canada) to guide relations between government and the voluntary sector (The Compact 1998; Accord Between the Government of Canada and the Voluntary Sector 2001).
Notwithstanding the above, there can be a high level of diversity in the nature of the relationships between government and the voluntary sector across different policy sectors of the same government (Coleman and Skogstad 1990: 25; Boris and Steuerle 1999: 14-5; Salamon 1999: 330). What is true in agriculture, for example, may or may not resemble what takes place in human resource development or in the cultural sector. One can often see a considerable amount of diversity even within the same policy sector (Coleman and Skogstad 1990: 29). This diversity, combined with the fact that this area has been relatively under-studied, means any generalizations must be approached with caution. Still, the area is too important to overlook, given the centrality of the voluntary sector to our subject. As Stoker puts it: “The governance perspective demands that these voluntary sector third-force organizations be recognized for the scale and scope of their contribution to tackling collective concerns without reliance on the formal resources of government” (Stoker 1998: 21). Focussing our discussion on the area of public health will help to narrow the range of circumstances to some degree, but even here, the relationships between government and voluntary organizations can be highly variable and complex.
Susan Phillips has provided a useful framework for an analysis of government-voluntary sector relationships – and one consistent with the notion of network governance – by suggesting that increasingly, governments must make a shift from governing by programming to governing by relationship-building. As Phillips points out:
Phillips goes on to argue for the need to shift “from traditional programming that focuses on hierarchy, accountability, and funding within a single department to relationship building that involves collaboration, co-ordination, responsiveness, and flexible accountability…” (Phillips 2001: 258).
Taylor expresses a similar notion in referring to the transition from a “contract culture to a partnership culture” (Taylor 1997: 21).
For our purposes, we need to ask how close the public health sector is to making that shift.
The voluntary sector in Canada
To even begin to answer the above question, it is necessary to situate the public health voluntary sector in the context of the broader voluntary sector in Canada, since that is the environment in which the former must function. In comparison to many other countries, Canada’s voluntary sector is quite robust. Based on a survey conducted in 2000 by Johns-Hopkins University and Imagine Canada, the share of the voluntary sector workforce (paid staff and volunteers) in the economically active workforce in Canada is second only to the Netherlands. (Hall et al. 2005: 9) Imagine Canada estimates that in 2008, the voluntary sector generated $106.4 billion in economic activity, or 7.1 percent of Canada’s GDP (Imagine Canada 2011). This study also found that the number of people involved in the voluntary sector in Canada was particularly high in the health and housing sectors (Hall et al. 2005: 13).
At the same time, however, literature in the field suggests that the voluntary sector in Canada has faced some serious challenges in the past decades. From about the mid-1990s, the sector came under significant scrutiny, in part because of issues raised by John Bryden, a Liberal Party member of Parliament from Ontario. Mr. Bryden asked a number of challenging questions about the accountability, transparency and representativeness of a number of organizations the government was funding (Miller 1998). To deal with the controversy surrounding the issue, Finance Minister Paul Martin Jr., initiated a review of the funding of “interest groups” in 1994. Concurrent with these developments, the federal government entered an intensive deficit-cutting exercise initiated in the 1995 federal budget. For the voluntary sector, this meant that there would be considerably less funding available. This dealt a severe blow to the sector which, since the 1960s, had become heavily dependent on government funding (Miller 1998: 408). Many VSOs had to absorb severe cuts to their budgets, and in some cases, funding was terminated altogether. This also meant the continuation, and probably acceleration, of a trend away from operational funding, sometimes called “core funding,” in favour of project funding (Phillips and Levasseur 2004: 453). Combined with this was a tendency in favour of contracts and contribution agreements of short duration, instead of the multi-year arrangements that had previously been more common (Ibid.: 457). The scarcity of funding meant that the competition for funding among VSOs became that much more intense (Imagine Canada 2007a: 8), and that these organizations had to account more rigorously for the money they received.
Faced with the challenges described above, it is probably not an exaggeration to describe the voluntary sector in the mid to late 1990s, as being in crisis (Miller 1998). Since the larger VSOs could still depend on outside revenue streams, the impact of these developments was more significantly felt by small- and mid-sized organizations. Still, the sector as a whole felt under pressure, and was searching for a way to establish itself on a stronger foundation.
Recognizing that there were important issues that needed to be addressed, the voluntary sector established the Voluntary Sector Roundtable (VSR) in 1995 to discuss the challenges faced by the sector. In 1997, the VSR initiated a panel, under the leadership of former N.D.P. leader Ed Broadbent, to examine how to improve accountability and governance in the sector, and how to improve the sector’s relationship with the federal government. The panel produced a final report titled Building on Strength: Improving Governance and Accountability in the Voluntary Sector, which was tabled in 1999. Among the 41 recommendations of this report was the creation of a joint federal government-voluntary sector task force to address the issues facing the voluntary sector.
Parallel to this, the federal government created in 1998 the Voluntary Sector Task Force (VSTR) for the purpose of developing a joint agenda and action plan. This was structured as a collaborative process with three joint tables which together produced a joint report called Working Together. This report formed the basis of the Voluntary Sector Initiative (VSI).
The VSI, which functioned from 2000 to 2005, was a $94.6 million joint initiative between the federal government and the voluntary sector to attempt to address some of the issues facing the voluntary sector. Its objectives were to: improve the relationship between the two parties; build sector capacity in the areas of finance, human resources, policy and knowledge and information management; and improve the regulatory and legal framework under which the sector operates (VSI Impact Evaluation, 2009: xi). The VSI had a number of positive accomplishments over its five-year term, including improved statistical information about the voluntary sector; recommendations on regulatory reform (although only a small number were actually implemented); an awareness campaign; policy internships and fellowships; a national learning initiative; and a number of tools, manuals and best practice information (Hall et al. 2005: 24).
The major outputs which had the potential of altering this relationship were An Accord Between the Government of Canada and the Voluntary Sector, and two “codes of good practice,” one dealing with policy dialogue and the other with funding. The accord was a high-level statement of principles which borrowed heavily from the compacts developed in the UK (Brock 2004: 170). The Policy Code was to provide guidelines for “open, informed, and sustained dialogue” between the voluntary sector and the government, while the Funding Code was to help guide interactions on funding policies and practices. Also of key importance from the perspective of engaging the voluntary sector in policy discussions with government was the sectoral involvement in departmental policy development (SIDPD). This program, which accounted for 30 percent of the total VSI budget, was to enhance opportunities in federal departments for policy input from VSOs, and to strengthen the capacity of VSOs to input into governmental policy-making exercises.
Notwithstanding the short-term accomplishments, it does not appear that the VSI had a long-term, or even medium-term, impact in changing the relationship between the voluntary sector and the government. The Voluntary Sector Initiative Impact Evaluation, produced by Human Resources and Skills Development Canada, concluded that the accord and the codes are not currently “living documents” and that they “neither guide nor improve the relationship between the federal government and the Sector or improve the capacity of the Sector in any significant or systematic way” (VS Impact Evaluation 2009: 14). The same evaluation concluded that there is limited evidence that the SIDPD projects had “any impact on increasing the mutual understanding of the government and voluntary sector” (Ibid.: 34). The two elements of the VSI that were deemed sustainable, were the Human Resources Council and the Satellite Account, both of which are research and survey based initiatives. (Ibid.: 57) Indeed, the evaluation implicitly raises a question about the commitment of government at the time to “true” collaboration when it states that: “In terms of opportunities for policy input and true collaboration, a desire on the part of government is necessary and should be in place if another VSI-like initiative is undertaken” (Ibid.: 52).
The federal government has acknowledged that “the VSI suffered goal overload and was unrealistic in its scope” (Ibid.: xii). At the end of the initiative, it put in place the Voluntary Sector Strategy (VSS), a four-year, $12 million program to complete the remaining elements of the VSI, which included conducting the impact evaluation.
Unfortunately, the VSI’s work was made more difficult by the “crisis” in grants and contributions at what was then Human Resources and Development Canada (HRDC) in 2000. The controversy was precipitated by an audit on management controls which suggested that many grants and contributions in that department had not been properly accounted for. The government response to these events was to impose a number of additional requirements on VSOs about how they must account for the monies they received (Phillips and Levasseur 2004: 451; Gibson et al.2008: 413). These requirements added significantly to the administrative load of organizations at a time when they were already dealing with staff cuts and insecure funding.
That the challenges for the voluntary sector continued following the VSI is evidenced by the report of Independent Blue Ribbon Panel on Grant and Contribution Programs. This panel reported in 2006 that many voluntary sector organizations “are in a fragile state, hostage to costly funding delays and to reporting requirements that many are ill-equipped to meet” (Blue Ribbon Panel 2006: 13). Although the language of “partnerships” is frequently used, “in most cases, the government has the weight and the authority to impose terms and conditions on its funding partners that they are hardly in a position to resist” (Ibid.: 2). Indeed, the Blue Ribbon Panel remarked that the uncertainty and instability affecting the voluntary sector was worse than ever. (Ibid.: 7) In their submission to the panel, the Canadian Council on Social Development (CCSD) wrote that: “Non-profits are being treated by government in a fashion that reflects a lack of faith in their trustworthiness and competence…” (Ibid.: 15) The same conclusion has been arrived at by Phillips and Levasseur (2004) and Gibson et al. (2008). Moreover, many of the Broadbent Report’s more far-reaching recommendations, such as establishing a Voluntary Sector Commission, identifying a Cabinet minister to articulate the concerns of the sector at the Cabinet table, and assisting voluntary sector organizations to develop the capacity for improved public reporting, still have not been implemented, and there is no evidence to suggest that they are even under consideration.
Returning to Phillips’ criteria, it would seem that governance based on relationship-building is still a long way off. The observations of the Blue Ribbon Panel and the CCSD, and even the impact evaluation, suggest nothing like “an enabling environment to permit partners to fulfill [their] potential…” Furthermore, no enforcement monitoring mechanism has been put in place “to ensure that government commitments on particular standards of conduct can be met by relevant departments…” The conclusion that the Voluntary Sector Accord and the Policy Code and the Funding Code are not currently “living documents” makes this all the more clear. Moreover, there is no longer a mechanism in place “to review and improve the relationship…” Finally, the “flexible accountability” posited by Phillips as a characteristic of governance by relation-building has not come to fruition. Indeed, as discussed, the governmental response to the HRDC events of 2000 has led to even more stringent requirements on funding arrangements with VSOs. Describing the effects of the accountability regime in place for VSOs as “overwhelmingly negative” for that sector, Phillips and Levasseur argue: “Above all, it is hurting the relationship between the federal government and voluntary organizations in significant ways because there is a considerable loss of trust.” (Phillips and Levasseur 2004: 464) More generally, the previously referenced report on the voluntary sector by Hall and his colleagues identifies a lack of coherent policy framework related to the voluntary sector in Canada, and cites this absence as “one of the biggest constraints to its future development.” (Hall et al. 2005: v)
The difficult climate for VSOs reflects a power imbalance between these organizations and governments, which has at times been likened to a David and Goliath relationship. (Phillips and Graham 2000: 171.) Project funding rather than core funding, short-term funding arrangements rather than multi-year funding, and an inflexible accountability regimes all suggest a desire by government for control in the relationship with the voluntary sector. From a policy perspective, VSOs are often relegated to the position of the “attentive public,” rather than as a “sub-government,” that is, as strong players in the policy process. (Pross 1986: 149) The consequence of this is that they find themselves at the consumer end of public policy, rather than being in a position to have a significant role in shaping policy. While common in Canada, as will be seen, this is not the only type of relationship between government and voluntary sector organizations that is feasible, or even appropriate. There are many international examples that can be drawn in which VSOs have a direct role in the public policy process, in some cases going so far as to include the ability to veto state proposals. (Salamon 1999: 353) On the other hand, the power imbalances reflected in “David and Goliath” government-voluntary sector relationships are not conducive to building trust between partners, which is consistently identified in the literature as a crucial element of collaborative governance. The consequence is the perpetuation of a relationship with government that in many respects fails to live up to its potential.
What makes the public health voluntary sector “special”?
The state of the relationship between the federal government and the voluntary sector sets the context for relationships with the public health sector. Referring to period of deficit-cutting in the 1990s, Colin McMillan, president of the CMA, and Seema Nagpal, pointed out that the “weakening of the partnerships between government and the voluntary sector […] tended to undermine efforts to develop public health programs based on the concepts of the Lalonde and Epp reports” (McMillan and Nagpal 2007: 62). What distinguishes public health somewhat from many other sectors is two-fold: the multiplicity and diversity of VSOs involved in public health; and the role of advocacy in the activities of these organizations and in public health in general.
As noted earlier, the voluntary sector is particularly active in the health field. It has been estimated that health sector organizations comprise 31 percent of the total workforce of the voluntary sector (Brock et al. 2007: 10). This relationship has deep roots. Chapter 1 referred to the creation in 1919 by the federal government of the Dominion Council of Health (DCH). In what may be seen as an early step in the direction of collaborative governance, the DCH was composed of the deputy minister of health, the provincial chief officers of health, as well as representatives of organized labour, women’s groups, social service agencies, agriculture and universities (Rutty and Sullivan 2010: 2.19). The purpose of the body was to advise the newly established federal Department of Health, and there is some indication that the DCH was in some ways “more important to the development of public health during the 1920s than the fledgling department it served” (Ibid.: 3.1). The Canadian Red Cross also played a major role, funding its own public health programs, and providing salaries for public health nurses to supplement what provincial governments, such as the one in Ontario, were providing (Ibid.: 3.3). In the area of emergency response, for instance, both the St. John Ambulance and the Canadian Red Cross were heavily involved in efforts to contain the 1918 influenza pandemic, and, in fact, are typically involved in most major crisis situations.
In more contemporary times, the length and breadth of public heath has inevitably led to a wide range of voluntary sector organizations involved in one of the many aspects of public health. Organizations might be engaged in preventing infectious disease such as avian flu, the West Nile virus, HIV/AIDS; behaviour-based strategies, such as smoking-cessation, alcoholism, unsafe sex, family violence, use of personal communication devices in automobiles, promoting physical activity, healthy eating habits, and sun safety; life stage related issues, related to children and seniors; gender-based concerns, most often related to women’s health, including maternal health; planning for emergency response; generic chronic disease prevention and control as well as disease specific activities (cancer, heart, lung etc.); settings-based strategies (school, work, communities, etc.); and groups taking a determinants of health approach, which tend to focus on poverty, housing and social justice. There are also a number of professional associations of physicians, nurses, nutritionists, physical therapists, psychologists and others which play an active role in the field. The end result is that it is very challenging for governments to determine with whom to collaborate and how, and for the organizations themselves to know which players are involved in the issues that affect them.
The second characteristic to be noted relates to the place of advocacy. The question of whether VSOs can be partners with governments and advocates at the same time has been and continues to be the fundamental tension in the relationship between the two (Young 1999: 59). This tension, therefore, is not unique to public health. Yet what gives this issue a particular saliency is that advocacy plays an integral role in public health (Chapman 2001: 1226). Public health practitioners, whether employed by governments, VSOs, or in private practice, see one of their roles as advocating for the types of changes in society that will lead to improved health of the population. This may lead to a greater willingness for public health agencies to enter into partnerships with VSOs to achieve shared objectives, leading to the multiplicity of relationships mentioned above. It can also lead to unorthodox, but not necessarily unusual, situations in which government representatives work alongside VSOs in campaigns to pressure their own governments to make particular changes to an area of public policy that affects health.
Three types of government-VSO relationships
It is clear that the voluntary sector has a key role to play in furthering public health. The nature of the relationships between the voluntary sector and government, however, is fraught with complexity. Some of the key questions to be answered include:
As a first step toward answering these questions, it is necessary to distinguish the types of relationships that exist in the sector. For this we will use Dennis R. Young’s typology of state/voluntary sector relationships at the national level in the US (Young 1999: 33). Young proposes these relationships be divided into three broad categories. What he calls the “adversarial” model is one where the main objective of the VSO is to pressure government to make public policy changes it considers necessary or advisable. These have often been called “pressure groups” or “lobby groups.” (See, for example, Pross 1986) What he calls the “complementary model” is one where VSOs – he uses the term “non-profit organizations” – are seen as extensions of government, in that they deliver programs and services financed by governments according to criteria and conditions established by government. Finally, the “supplementary model,” is one where the VSO “fulfills demands for a public good left unsatisfied by government.” In this case, the VSO fills a gap that the state either can not or will not fill itself.
Interestingly, Young’s typology corresponds quite closely to the one proposed by Coleman and Skogstad some years earlier to describe different types of policy networks: pressure pluralism (adversarial model), state-directed networks (complementary model), and clientele pluralism (supplementary model) (Coleman and Skogstad 1990: 26-30).2 We will draw from both in applying these three categories to the public health sector in Canada.
The adversarial model
In this instance, the ultimate objective of the VSO is to influence public policy in a way to advance its particular cause.3 Whether by choice or necessity, it is not dependant on the state agency (at the national level, either the Public Health Agency of Canada or Health Canada) for financial support or other resources. This financial independence frees it from “the ‘whims and rules’ of the funding agency” (Grieve, 2003: 117), although it could also mean that the organization pays a high price for its “freedom,” in that it lacks the resources to be effective in advancing its cause. While the state agency cannot control this type of VSO, it may well be sympathetic to its objectives and at times even lend some form of “moral” support. In some instances, representatives of the state agencies may participate in processes led by the VSO, which can lead to situations, where the representative of the state agency participates in an endeavour that seeks to influence public policy, thereby conflating the public health advocacy role with that of public servant. We include in this category VSOs which receive no funding or direct assistance from PHAC or Health Canada, as well as the larger VSOs who may receive some support from those agencies, but whose funding base is so large and diverse (including from different sources within the federal government) that this support does not put them in a position of dependence. On the other hand, the relationship inherent in the adversarial model is such that it tends to put considerable distance between the VSO and the public policy development process, thus relegating those organizations to the position of the “attentive public,” as opposed to a more substantive “sub-government” role.
Without attempting to claim that these are necessarily “representative” – a claim that would need to be substantiated by a comprehensive study of VSOs in the public health sector, which is beyond the scope of this book – the examples below are meant to illustrate these types of relationships. The information provided is based on document review, supplemented by interviews with key informants as noted.
Prevention of Violence Canada
There is no dedicated secretariat and the co-chairs take their role on a rotational basis. The POVC actively draws from the international community, adopting the WHO Preventing Violence: A Guide to Implementing the Recommendations of the World Report on Violence and Health as the framework for the national violence prevention strategy (Ibid.).
The POVC is an advocacy organization; it does not seek a programmatic role for itself. The funding it seeks to support violence prevention, largely from the Public Health Agency of Canada (PHAC), is intended for organizations working in the area, depending on the nature of the activity, rather than attempting to carry out the activities itself. Over the years, it has received small amounts of funding to allow it to stage a town hall meeting, to allow its members to travel to some international meetings, or to cover the costs of some teleconferences for its members. The level of funding received was not significant or regular enough to compromise its independence. However, the key informants interviewed felt quite distant from the government apparatus and the public policy-making decision-making process (Interview #1, July 12, 2010; Interview #2, July 20, 2010). Indeed, a good part of their advocacy work revolved around strengthening their relationship with the federal government agencies, so it could have a stronger role in the policy process as it relates to the prevention of violence (Interview #1, July 12, 2010).
Federal representatives, primarily from the Public Health Agency of Canada, have provided “moral support” to the POVC, and at times have provided advice to POVC leaders on strategy and tactics, while at the same time abstaining from voting on initiatives, conscious of their ambivalent status. Representatives from provincial and territorial governments also participate in POVC discussions, which are less problematic for provincial/territorial representatives, since the network primarily seeks to influence policy at the federal level.
Safe Communities Canada
Historically, Safe Communities Canada has not received significant funding from the federal government. Its financial support derives essentially from three sources: project grants from provincial workers’ safety boards (47 percent); contributions from the corporate sector (23 percent); and sales of products and tools to provincial agencies and foreign countries, such as Australia (30 percent). Although its main focus has been at the program level, Safe Communities Canada has come to the conclusion that it needs to have much more impact at the national policy level. As a result, it has recently entered into discussions with the three other major injury prevention VSOs – Safe Kids Canada, Smartrisk, and ThinkFirst Canada – to discuss the possibility of merging into a single organization. The motivation for this integration is precisely to be more effective at engaging the federal government in policy discussions, with the objective of establishing injury as a stand-alone health category, which the organizations believe is not now the case. The new organization would be expected to compete more effectively with other public health VSOs for the attention of federal government agencies, such as Health Canada and PHAC, including the opportunity to receive funding from those agencies. Ideally, the new organization would eventually find itself in a position of participating in joint planning and decision-making processes with the federal government.
Although Safe Communities Canada has maintained its independence from the federal government and, therefore, its ability to take the policy positions it considers appropriate, its formal relationship with that government is sub-optimal (Interview #3, July 14, 2010). Specifically, its ability to enter into policy discussions is at best sporadic. The government’s decision, announced in the March, 2010 Speech from the Throne, to fund a national strategy on childhood injury prevention, while providing some modest funding to the organizations, has not led to any significant changes in the relationship between these groups and the federal government (Interview #4, March 2, 2011). The decision of the four injury prevention groups to even discuss seriously the possibility of merging into one can be seen as an eloquent expression of the perception of these organizations as being marginalized in the policy process. The possibility of integration with others is no doubt a painful decision for many in those organizations, implying as it does not only having to abandon their respective institutional “brand,” but also that several staff positions would be affected, starting at the top, where three individuals would have to relinquish their positions as president in favour of the fourth. Although these efforts ultimately may not bear fruit, the incentive to seriously consider taking this step would need to be very powerful, demonstrating that for these groups, the status quo ante is seen as being unacceptable.
Centre for Science in the Public Interest
While maintaining its independence from government, the CSPI participates actively in various fora established by government, and is not reluctant to take public positions critical of the government when it feels this is warranted. For example, it is a regular participant in consultations by Health Canada on issues related to nutrition and participates actively on working groups to look at various aspects of food policy.
While the CSPI welcomes opportunities to participate in point planning or policy development exercises, as it did with the Sodium Working Group and the Trans-fat Task Force, it guards its independence carefully. A key informant from the CSPI indicated that they would participate in such exercises only on condition that they maintain the right to express a dissenting opinion if they disagreed with the majority view (Ibid). The CSPI sees most of its focus consisting in pressing for public policy changes from the outside, and is wary about working too closely with government. The organization sometimes encounters difficulties enlisting the support of other public health VSOs for various advocacy campaigns, perhaps due to the concern on the part of these organizations to maintain, or at least avoid damaging, their relationships with government (Ibid.).
To encapsulate, the above examples are meant to illustrate cases where the VSO, whether by necessity or by choice, have remained independent from government, thus allowing them to take positions they consider appropriate. At the same time, those groups operate outside the formal public policy process, and have few tools to influence it, other than persuasion of government representatives, participating in consultations when they are held, or resorting to such devices as letter-writing campaigns or appeals through the media. The level of actual collaboration between these VSOs and government agencies, therefore, whether by necessity, by choice, or both, is at best quite limited.
The complementary model
In the complementary model, the relationship between the state and the VSO is one in which there is a clear power imbalance, with the state being the dominant actor. As Phillips and Graham point out “…governments are often guilty of assuming that the weight of their dollars give them the authority to dictate accountability mechanisms and policy directions, rather than to negotiate them” (Phillips and Graham 2000: 180). Essentially, the state agency maintains its control, consciously or otherwise, through the use of financial transfers. With the federal government, this generally takes two forms: grants and contribution agreements.4 The former is meant to refer to transfers where there are fewer conditions and less onerous reporting requirements than in the case of contribution agreements. In reality, the two mechanisms often resemble each other, with more conditions attached to grants than might normally be expected (Blue Ribbon Panel, 2006: 3). Although care is taken to avoid a principal-agent relationship in the strict sense, (see Salamon, 1999: 349 for a discussion of this relationship), the funds are provided to a VSO as part of a policy or program objective the government wishes to pursue.
Because many VSOs in this situation essentially depend on government transfers to remain in existence, the priorities and original mandate of the organizations can easily become distorted as they pursue government funding opportunities (Building on Strength 1999: 5). Over the long term, this tends to diminish the independence of an organization that falls within this category, as it begins to resemble “a quasi-governmental entity” (O’Connell 1996: 224). In such instances, the VSO risks losing credibility in the eyes of other VSOs as well as with its own members (Pross 1986: 198; Interview #5, September 8, 2010; Interview #6, June 24, 2010). Somewhat paradoxically, such an unequal relationship can even limit the VSOs value to government. While more convenient for the state agency in the short-term, it also deprives its representatives of an opportunity to enter into a more fruitful policy dialogue which could be more beneficial to both parties.
As stated earlier, the tendency of VSOs to be more tightly controlled by the state has probably increased since the mid-nineties. VSOs can be quite resilient and highly creative, even under pressure from reduced funding opportunities and additional accountability requirements. In many cases, they are often quite capable of finding ways to express their views on policy issues, directly or indirectly. Yet for those VSOs in this category, dependence on government funding remains an inescapable factor in shaping their relationship with government and ultimately to the broader VSO community. This is, in particular, the case with smaller organizations dependent primarily on one revenue source. Even in the case of the voluntary sector initiative, a joint federal government-voluntary sector intervention which was designed to reflect a spirit of partnership and horizontality, the accountability mechanisms in the contracting arrangements essentially undermined the collaborative aspect of the relationships (Phillips 2004: 13).
Examples of VSOs in the public health sector which fall in this category include the multitude of organizations receiving funding under the PHAC’s community-based programs, such as the Community Action Program for Children (CAPC), and the Canada Pre-natal Nutrition Program (CPNP). CAPC and CPNP, which are PHAC’s largest contribution programs by a considerable margin, with annual budgets of $55 million and $26 million respectively, are structured to involve consortia of local organizations to engage in a range of initiatives to improve the circumstances of at-risk children. Organizations involved might be hospitals, housing corporations, service organizations, professional associations, and many others. Large organizations can be involved, but the majority tend to be relatively small community organizations. Although a high percentage of these groups receive funding from other sources, the federal government funding is often seen as the centrepiece around which other funding is assembled (Interview # , July 20, 2010). In many cases, without the funding from PHAC, they might cease to exist, or at least be forced to drastically curtail their operations. The same could be said for many organizations receiving funding from a number of PHAC programs.
The point to be made is not that these organizations necessarily feel frustrated that they do not have a stronger role in the policy process. In many cases, their primary goal is to provide a service they consider important and beneficial, not to participate in policy discussions. Also, as Salamon points out, in complex principal-agent relationships, the agent can sometimes end up with more significant control than the principal (Salamon 1999: 349). In general, however, what these relationships reflect is a significant power imbalance in favour of the state. The fact that most of the funding agreements are of short duration – recently they have been held to one- or two-year renewals – serves only to underscore the unbalanced nature of these relationships.
The supplementary model
As referenced earlier, Young describes this model as one where outside agencies perform a role or provide a service that the state agency either will not or cannot provide. In these cases, the level of the relationship is on a much more equal basis than is the case with the complementary model. The VSO may be dependent on the state agency for financial support, but at the same time, the state agency is dependent on the expertise that the VSO possesses. Entering into such relationships may be viewed as an admission by the state agency (sometimes grudgingly made) that it does not possess the knowledge or capacity to carry out a particular activity or strategy. In such cases, the role of the state agency is quite circumscribed, largely restricted to providing funding, and allowing the VSO a greater than usual amount of discretion with the use of that funding. Using the terminology described earlier, the VSO involved in such a relationship is acting more in terms of a “sub-government” than as a member of the “attentive public.”
Interestingly, this type of relationship is both young and old in the health sector. In the early part of the 20th century, many health institutions in some provinces, such as TB sanatoria and hospices, were left to the private sector to administer, particularly faith-based organizations (Rutty and Sullivan 2010: 3.7). Catholic and Anglican missionaries were also left to operate small hospitals in the North. Similarly, in the 1940s, the Canadian Red Cross provided many of the district nurses in remote areas (Wallace, 1948: 175-176). Another example is the Canadian National Council for Combating Venereal Diseases (later renamed the Canadian Social Hygiene Council), a VSO which implemented VD campaigns in most provinces and major cities (Rutty and Sullivan 2010: 3.10). As the municipal, provincial and federal governments developed and expanded their competencies, particularly following the Second World War, they asserted control over many of these services. The more modern manifestation of this model, however, provides an interesting and promising departure from the more conventional models. Two recent cases can be made to illustrate this point.
Canadian Partnership Against Cancer Corporation
The CPACC model is a major departure from either the adversarial model or the complementary model. In his case study of the CPACC, Michael Prince described the Cancer Strategy as “a platform for communication between governments, non-government agencies, health professionals, and cancer survivors and families” as well as “an opportunity to modernize the management of chronic diseases and to further democratize the conduct of intergovernmental relations. (Prince 2006: 468). In fact, the CPACC’s mandate goes well beyond this. The CPACC is a case where the VSO, as a result of a decision made at Cabinet, has been given policy authority and financial resources to implement a national cancer prevention strategy (Interview #8, September 23, 2010; Interview #9, September 27, 2010). This may well be unprecedented in modern times in the health sector. In a sense, CPACC represents a case where the tables have been turned against the government. As a consequence, Health Canada and the Public Health Agency of Canada often find themselves in the position of participating, not as parties with a stronger role than any other organization, but as one of many parties. If either agency has a particular interest in one of the eight strategic priorities, or in a sub-strategy within them, it may decide to participate more actively by contributing funding for a particular purpose. This was the case recently when PHAC and Heart and Stroke Canada contributed funding to CPACC for the Collaboration Linking Science and Action (CLASP) programs to integrate cancer and other chronic disease prevention programs. Because they were providing funding, both organizations received a seat at the table to participate in steering those programs.
Although funded by the federal government (primarily Health Canada) and reporting to the Minister of Health, the CPACC clearly enjoys a great deal of autonomy from that government. The fact that the government’s funding commitment was over a five-year time horizon, and can be extended, further reinforces this level of autonomy. CPACC was also given the authority to provide funding to third parties, thus conducting its own calls for proposals, and the flexibility to reallocate funding across priorities, as it determines appropriate, both of which are unusual, though not unprecedented (Interview #10, September 11, 2010). Instead of a power imbalance in favour of the state agency, as in the other two categories, the establishment of the CPACC represents an attempt to establish a different type of relationship. There has been some speculation about the motivation behind the federal government’s decision to establish and fund the CPACC as it did. Prince suggests that the strategy may have been a response to public pressure for federal and provincial governments to work more closely together on cancer control and other health issues. He also suggests that the reports from the Kirby Senate Committee and the Naylor Report, as well as the report from the Romanow Commission may have contributed by adding pressure to the calls for reforms to health care policy, delivery and governance in Canada (Prince 2006: 471). Beyond these more “political” factors, the CAPCC/CSCC also presented an opportunity to build from a knowledge base beyond what state agencies could offer. The fact that all three major political parties supported the CSCC in the 2006 election campaign suggests a consensus that the existing governmental apparatus, for whatever reason, was not capable of achieving the goals of a national cancer strategy. Whatever the motivations that led to it, the fact remains that what was created was a dramatically different model from what has typically been the case.
The Mental Health Commission of Canada
Since its inception, the MHCC has worked on developing a mental health strategy, which it is doing in two stages. In the first stage, it developed a framework for such a strategy, titled Toward Recovery and Well-being, which was released in November 2009. The second stage consists of developing a comprehensive strategic plan for how to achieve the framework. In addition, it is working on developing anti-stigma initiatives; conducting research demonstration projects on homelessness issues; engaging in knowledge exchange; and developing a network of partners in the mental health area.
There are similarities between the MHCC and the CAPCC in that, in both cases, the government considered it necessary to go outside the formal bureaucracy to accomplish its objectives in these areas. More specifically, the government considered that it lacked the capacity, or was not strategically placed, to deal effectively with the issues of cancer prevention or mental health respectively. The MHCC falls short of the CAPCC mandate in that it is charged only with developing a mental health strategy, and did not receive the policy authority or the funding to implement this strategy, although it is conceivable that this could be viewed as a next step. Furthermore, the MHCC did not receive a mandate from Cabinet, but was established using the Prime Minister’s prerogative (Interview #11, April 1, 2011). Still, it represents a departure from the more typical relationships represented by the “adversarial” and “complementary” categories. To begin with, its agreement with Health Canada is that it will not engage in advocacy, which differentiates it from “adversarial” categories. While this can be seen as a restriction to its activities, it is more significant in underlining that rather than being on the outside advocating for changes; it is a central part of the public policy apparatus dealing with a difficult issue. In other words, it is not an outsider looking in, but rather the other way around.
Second, while it receive its “core” budget from Health Canada, its ten-year mandate, as well as the latitude it has received to develop a framework and a strategy for mental health, does not reflect the same type of power imbalance as the organizations in the “complementary” category. Similar to the CPACC, it acts as a funding agent in its own right, providing funding to other VSOs in the mental health area. Furthermore, as with the CPACC, government departments, such as PHAC and Human Resources and Skills Development Canada have provided funding to partner for specific projects, but in these cases, it is the MHCC, and not the government department, that is the “senior partner.” While not being as ground-breaking as in the former case, the MCHH remains significant in that it establishes the basis for a different relationship between the state agency and the VSO. Perhaps the best indicator of the “out of the box” nature of both the CPACC and the MHCC is that central agencies, such as the Treasury Board Secretariat, are reported to have expressed considerable concern and even discomfort about the terms for the establishment of both entities (Ibid.).
Categorizing the many relationships that exist in the public health sector runs the risk of over-simplifying what are often very complex situations. As Young acknowledges, the categories above should not be seen as mutually exclusive. Many combinations and permutations can and do exist in the “real” world. We will look at just two such examples.
The Canadian Strategy on HIV/AIDS
The key aspect of Tsasis’ article is to examine the power relationships between the VSOs and Health Canada. The author makes a convincing case that a significant power imbalance existed in that relationship, which was used by Health Canada to “exercise power in many integral facets of their activities” (Ibid.: 271). He goes on to say that the VSOs found their advocacy role curtailed by Health Canada’s “formalization and bureaucratization” and that while Health Canada referred to the arrangement as a “partnership,” from the perspectives of the VSO participants, the power imbalance inherent in the relationship made it a “pseudo partnership” (Ibid.: 273).
Tsasis goes on to show that over time, the VSOs were able to neutralize, to some extent at least, that imbalance by forging strong relationships between each other, and drawing on the social capital they had built as a result of their activities at the community level. In so doing, they were able to re-balance their relationship with Health Canada. Tsasis concludes from this that “a dependent organization can gain leverage over the dominant organization by co-opting actors who can constrain, through their influence, the actions of the dominant organization in a way that favours the dependent organization” (Ibid.: 285). In the end, however, although the VSOs were pushing back against Health Canada’s dominance, their actions were essentially defensive in nature, and did not alter the fact that what was involved was at its base an “us” and “them” relationship, seemingly based on a lack of trust.
Canadian Breast Cancer Initiative
On the other side are voluntary sector representatives, in particular, those involved in the Canadian Breast Cancer Network. In contrast to the professional groups, Grieve describes the relationship in these cases as being more characteristic of the complementary model that is essentially acting as delivery agents for the state. Rather than being part of the “sub-government,” as was the case with the professional organizations, these tend to be confined to the role of the “attentive public,” whose main levers to influence policy is through the media (Ibid.: 105). What emerges from this is a complex picture where there are different levels of inclusion within the same policy community: that is between those who have a previously established relationship to government and those who must play on the margins. Based on the proliferation of groups, leading to further fragmentation of views and competition (not collaboration between them), and a weakening relationship between the government and the Canadian Breast Cancer Network, Grieve sees reasons to doubt the long-term influence of the voluntary sector in this area (Ibid.: 120).
Conclusions: A base to build on?
The picture of the relationships between the government and the voluntary sector in the public health field is thus a complex one. How does one put this in perspective and what does it this mean for the prospects for network governance? Recognizing that Phillips’ model of governance by relationship building is still somewhat of an ideal-type, one can legitimately ask how far we have progressed down this road. Our conclusions will need to be tentative, in part because, as Klitgaard and Treverton have noted, “we are not even close to having a model to assess partnerships” (Klitgaard and Treverton 2004: 50). Still, some observations can be made, preliminary though they might be.
First, the adversarial model, as reflected in the cases reviewed, represents only a very weak form of collaboration, if indeed it is one at all. In these instances, neither the state party nor the voluntary sector party is committed to working together, although this can change if the government agrees to provide tangible support for a particular initiative. Although there may at times be joint tables or fora, these will tend to be more informal or sporadic, unless the organization, as is the case with the CSPI, has an independent funding source. There is far less possibility that there will be an agreement on joint planning and activities. There may be participation of government officials in some discussions led by the VSO, as we have seen, but the conflict in roles will inhibit the full participation of the government representative. In this model, the VSO will be in the position of the “attentive public,” with very few policy levers to effect policy change.
The complementary model, by which the state will attempt to achieve its policy objectives by using the voluntary sector as its delivery vehicle, is different from this in the sense that it is based on a formal relationship. The state agency and the VSO will have agreed to some common goals which the VSO will carry out with agency funding. The VSO, if it is creative, can enjoy a fair measure of autonomy, which from a legal liability perspective, the government will seek to encourage (Interview #10, September 23, 2010). Whether this remains ultimately a principal-agent relationship can be debated, but the fact remains that this is a relationship of dependency favouring the state party. The power imbalance implied from such a relationship is hardly conducive to trust-building or collaboration.
CPACC, and to a somewhat less extent, the MHCC, appear as the clearest examples of the supplementary model. Although funded primarily through the federal government, the VSO in these cases functions in a sub-government capacity, acting as a third-party funder, while maintaining an arm’s-length relationship with government. It is possible to argue that the CAPCC model in particular may simply have turned the complementary model on its head. Instead of the VSO party being the junior partner to government, with the CAPCC, it is now the VSO that is in the driver’s seat with the state party confined to a secondary role. Interviews with key informants, however, suggest that the relationship appears to be evolving (Interview #9, September 27, 2010; Interview #8, September 23, 2010; Interview #12, June 10, 2010). Whereas in the first years, both parties seemed to be eager to keep each other at a significant distance, more recently some joint activities have been initiated, as with the CLASP initiative mentioned above. How the relationship will evolve still remains to be seen, as does the question of whether the government will choose to replicate this model. It does, nonetheless, create the potential for a qualitatively different type of relationship and one more consistent with modern governance than what conventionally has been the case. On the surface, at least, these seem considerably more consistent with Phillips’ characterization of governance by relationship-building involving “collaboration, co-ordination, responsiveness, and flexible accountability.”
Aside from these two cases, the overall picture that emerges regarding the relationship between the government at the national level, primarily the Public Health Agency of Canada and Health Canada, and the voluntary sector may be described in the following way:
First, what one finds is a pattern characterized by a high level of diversity and complexity, with a very large number of VSO players, and quite a number of different arrangements that have been negotiated over a long time horizon.
Second, there is an apparent lack of an overarching strategic approach or framework in either Health Canada or the Public Health Agency of Canada to guide arrangements with the voluntary sector. Rather, such relationships emerge on a case-by-case basis, according to particular circumstances of the case. Key informants with whom we spoke suggested that the nature and level of engagement with VSOs was often dependent on the personality of the senior official responsible for that area (Interview #6, September 8, 2010; Interview #13, February 17, 2011).
Third, while relationships with the voluntary sector are no doubt valued, as evidenced by the prevalence of such relationships in the sector, there is a lack of a mechanism to nurture relationships with the voluntary sector, and to conduct a systematic and transparent review of these relationships to determine their level of effectiveness and satisfaction from the perspectives of the parties involved, and to learn from these experiences. Health Canada did conduct a survey on “stakeholder discussions” in 2010, but this was not made public and was carried out as a “one-off” initiative (Interview #13, February 17, 2011). The PHAC commissioned a study in 2007 to “identify linkages and gaps in current research on voluntary organizations and volunteers as they relate to health…”, and to provide options on how to proceed to fill those gaps, but there does not appear to have been follow-up to this study (Brock et al. 2007).
Fourth, the relationships are typically characterized by a distinct power imbalance between the government agencies and the VSOs. The adversarial and complementary models are not such as to allow for joint planning or inclusive policy-making discussions, and thus tend to keep VSOs on the margins of the development of public policy. Furthermore, as discussed in chapter 3, there is no mechanism to discuss public health policy at a broader level with the voluntary sector, for example, within the Pan-Canadian Public Health Network (McMillan and Nagpal 2007: 64).
We seem, then, to be some distance away from a clear direction toward what Phillips described as governance by relationship-building. Although partnerships are frequently referenced by the government agencies as being central to public health (see for example, Report of the Chief Public Officer of Health, Public Health Agency of Canada 2008: 8), the reality seems to fall far short of this vision. This is not to be unduly critical of the PHAC or Health Canada. As discussed earlier in this chapter, there are distinct challenges surrounding the relationships between the voluntary sector and the federal government as a whole. Indeed, the public health sector may well have gone further than many other federal government departments and agencies in reaching out to outside parties.6 Furthermore, as Hall and his associates reported in their survey, the number of VSOs involved in health is particularly high compared to other policy areas in Canada, making the challenge of how to build effective relationships with such a large number rather daunting. Yet, it is clear that much more remains to be done before a model of governance by relationship-building can be realized.
Network governance assumes a much deeper sense of involvement of relevant stake holders, including the VSOs, than what has been observed in the public health sector to date at the national level. New mechanisms and behaviours are necessary that are not based primarily on institutional or contractual arrangements, legislation, and inflexible forms of accountability (Karmensky et al. 2004: 19). This will not be easy. Without those steps, however, the opportunities of realizing appropriate forms of network governance in the public health area will be lost.
Claude Rocan is a Research Fellow at the Graduate School of Public and International Affairs at the University of Ottawa. He was previously Director General of the Centre of Health Promotion at the Public Health Agency of Canada.
1 This definition is consistent with that used in Building on Strength: Improving Governance and Accountability in Canada’s Voluntary Sector, (Broadbent Report), 1999: 7; see also Morison, 2000: 98.
2 Two other categories proposed by Coleman and Skogstad, “parentela pluralism” and “closed systems” are not applicable because, in the first case, the category does not apply to the national level, and in the second, the public health environment is too fragmented to operate as a closed system.
3 The use of the term “adversarial” can be misleading, since, as will be seen below, the relationship with the government agency can be positive as well as negative.
4 We will not discuss government contracts, since that does not go beyond what is essentially a commercial relationship.
5 As mentioned, the CSCC is not meant to cover the entire cancer universe. Where there are instances of joint interest, the CAPCC and the Health portfolio (Health Canada and the Public Health Agency of Canada) have been instructed to ensure the actions of one informs the other.)
6 Still, some sectors have developed more elaborate forms of collaboration. Following a review of the roles of NGOs in intergovernmental relations, Julie Simmons identifies the Canadian Council of Ministers of the Environment (CCME) as “the most transparent and systematic of intergovernmental forums in routinely integrating non-governmental actors into its policy development.” (Simmons 2008: 367)
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