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Abstract: Accountability for reasonableness is an ethical framework for fair priority setting process. This framework has been used to evaluate fairness in several contexts, and a few studies have evaluated its acceptability to decision makers. However, no studies have compared the acceptability of the four conditions of the framework to decision makers across health systems and levels of priority setting. This paper reports the elements of fairness described by 184 decision makers involved in priority setting at the macro-, meso- and micro-levels of priority setting in the Canadian (Ontario), Norwegian and Ugandan health care systems and compares them against the four conditions of ‘Accountability for Reasonableness’ and across levels of decision making, and health care systems. Our respondents identified 23 elements of fair priority setting. Most of these (17) were well aligned with the four conditions of Accountability for Reasonableness; six were not. Comparisons across health care system and levels of decision making revealed that four elements (transparency, participatory and among the criteria—need based and objective) were common to all and the rest were common to only the health care systems (but not at all levels), or only the levels of decision making (but not to all health are systems). Perceptions varied remarkably across levels of decision making. The overlap between the elements of fairness found in this study and the conditions of Accountability for Reasonableness demonstrates that the four conditions are recognizable and applicable across health care systems and levels of decision making. However, the framework should be used with flexibility to allow for identification of elements and relevant explicit criteria (such as those identified in this study) – that may not directly fit under any of the four conditions. [Copyright &y& Elsevier]

Abstract: This paper contributes to the literature on the geographies of care and caregiving by examining the implications of weather for providing home and community care for children and older adults. Integrating research from two previous qualitative studies of formal and informal care provisioning in Ontario, Canada, the authors re-analyzed semi-structured interviews with 83 directors, managers, paid staff, volunteers and family members to examine the challenges they faced when providing care during the winter season. Similar to other settings where winter conditions like snow, ice and cold temperatures are commonplace, the studies were set within a health policy context in which there is not enough recognition of the difficulties of weather for coordinating, managing and providing care to disabled, injured, chronically ill and frail individuals. The re-analysis focused on how winter conditions translate into geographical, administrative, economic, operational, physical, social and psychological barriers within and across different ‘scales of care’. The findings indicate that the problems posed by weather are crucial yet often underestimated aspects of home and community care provided by formal and informal caregivers. The analysis of weather-related challenges for care provisioning needs to be extended to other seasonal conditions (e.g., the challenges of delivering care in extreme heat), to the developing world and even to the burgeoning debates on the health implications of global environmental change. [Copyright &y& Elsevier]

Abstract: This paper contributes to the current debates surrounding private delivery of health care services by addressing the distinctive challenges, constraints and opportunities facing for-profit and non-profit providers of long-term care in rural and small town settings. It focuses on the empirical case of Ontario, Canada where extensive restructuring of long-term care, under the rubric of managed competition, has been underway since the mid-1990s. In-depth interviews with 72 representatives from local governments, public health institutions and authorities, for-profit and non-profit organisations, and community groups during July 2003 to December 2003 form the platform for a qualitative analysis of the implications of managed competition as it relates to the provision of long-term care in the countryside. The results suggest that the introduction and implementation of managed competition has accentuated the problems of service provision in rural communities, and that the long-standing issues of caregiving in rural situations transcend the differences, perceived or otherwise, between for-profit and non-profit provision. Understanding the implications of market-oriented long-term care restructuring initiatives for providers, and their clients, in rural situations requires a re-focussing of research beyond the for- versus non-profit dichotomy. [Copyright &y& Elsevier]

Abstract: This paper examines the efforts of two complementary and alternative occupations, chiropractors and homeopaths, to move from the margins to the mainstream in health care in the province of Ontario. We use a variety of theoretical perspectives to understand how health occupations professionalize: the trait functionalist framework, social closure, the system of professions, and the concept of countervailing powers. The research traces the strategies that the leaders of the two groups are employing, as well as the resources they are able to marshal. These are analyzed within the context of the larger institutional and cultural environment. The data are derived from in-person interviews with 16 leaders (10 chiropractic and 6 homeopathic) identified through professional associations, teaching institutions and informants from the groups. The responses were analyzed with qualitative content analysis. We also used archival materials to document what the leaders were telling us. The data revealed four main strategies: (1) improving the quality of educational programs, (2) elevating standards of practice, (3) developing more peer reviewed research, and (4) increasing group cohesion. Although both groups identified similar strategies, the chiropractors were bolstered by more resources as well as state sanctioned regulation. The efforts of the homeopaths were constrained by scarce resources and the absence of self-regulation. In both cases the lack of strong structural support from government and the established health professions played an important role in limiting what was possible. In the future, it may be to the state''s advantage to modify the overall shape of health care to include alternative paradigms of healing along with conventional medical care. Such a shift would put complementary and alternative medicine occupations in a better position to advance professionally and become formal elements of the established health care system. [Copyright &y& Elsevier]

Abstract: The rise of neo-liberalism, which suggests that only markets can deliver maximum economic efficiency, has been a driving force behind the trend towards using market-based solutions to correct health care problems. However, the broad application of market-based reforms has tended to assume the presence of fully functioning markets. When there are barriers to markets functioning effectively, such as the absence of adequate competition, recourse to market-based solutions can be expected to produce less than satisfactory, if not paradoxical results. One such case is rehabilitation homecare in Ontario, Canada. In 1996, a “managed competition” model was introduced as part of a province-wide reform of home care in an attempt to encourage high quality at competitive prices. However, in the case of rehabilitation home care services, significant obstacles to achieving effective competition existed. Notably, there were few private provider agencies to bid on contracts due to the low volume and specialized nature of services. There were also structural barriers such as the presence of unionized employees and obstacles to the entry of new providers. This paper evaluates the impact of Ontario''s managed competition reform on community-based rehabilitation services. It draws on data obtained through 49 in-depth key informant interviews and a telephone survey of home care coordinating agencies and private rehabilitation provider agencies. Instead of reducing costs and improving quality, as the political rhetoric promised, the analysis suggests that providing rehabilitation homecare services under managed competition resulted in higher per-visit costs and reduced access to services. These findings support the contention that there are limits to market-based reforms. [Copyright &y& Elsevier]