Presented at BuildingPolicy4the Social Economy Policy Colloquium Halifax, NS October 2, 2009 1
Share preliminary insights into a 3 province comparative analysis of provincial public policy, paying attention to the sharing of responsibility and cooperation among four sectors in order to improve the quality of Public Policy (PP) for aging persons: Public Sector or State, Private for Profit Sector or Market, 3rd Sector (social economy and community based organizations) 4th Sector or informal sector (family/friend caregivers) Advance thinking on Co-production and Co-construction of Public Policy as it is related to publicly funded home care services. Research Questions about Co-P and Co-C 2
Co-production = provision of PP Co-construction = design of PP Configurations of co-production of PP 1. 2. 3. Provision mainly from the for-profit private sector = PRIVATIZATION ) Provision coming mainly from the SE & CBOs Provision coming mainly from the Informal Sector (Familialization) Scenarios about Co-construction in PP: 1. Presence of a Neoliberal Co-construction 2. Presence of a Corporatist Co-construction 3. Presence of a Democratic Co-construction Interfaces State/Market/Third & Fourth Sector 1. Quasi-market or competitive ( managed competition ) 2. Partnership & cooperation ( regulated cooperation ) 3. Hybrid -mixed PP with quasi-market and partnership pieces 3
Social Economy Public Sector Voluntary organizations Provincial Home care programs Advocacy and support groups Federal /prov taxation policy Family/friend Spouse, children, relatives Friends/neighbours Private/Business For-profit agencies Autonomous workers 4
QUEBEC NOVA SCOTIA NEW BRUNSWICK 95 CSSS in 18 H&SS Regional Agencies (AVQ) 9 Health Districts 2 Health Authorities SOCIAL ECONOMY + CBOs 500 Community and Voluntary Org 101 Social Economy enterprises (home support/avd) 21 NFP agencies Home support +4 VON agencies health & HS CBO # s unknown NFP in all regions - 20 agencies CBO unknown PRIVATE for Profit in Urban areas FP agencies + Autonomous workers hired with CES or Self managed care or through underground economy in Urban areas used for overflow Autonomous workers: for self managed care Concentrated in Urban areas 34 agencies - Clients may receive $$ to contract provider PUBLIC FAMILY carers (health hc) 7 Regions (home support) Provide 70% of the hours of care in the community to older persons requiring support (Lafreniere et al., 2003) 5
*New Brunswick estimates include Dept Community Services home support services to all age groups; complete data for 2004-05 not available. Source: Canadian Home Care Association (2008). Portraits of Home Care in Canada 6
1970-80 s Home care delivered by Municipalities 1988 Coordinated Home Care Program (provincial) 1993 Homemaker services shifted from Dept of Community Services to Health 1995 Home Care Nova Scotia (HCNS) introduced and expanded eligibility 2000 Integration of home care, facility care, adult protection into Health s Continuing Care 2002 Single entry access to long term care 2006 Continuing Care Strategy 2009 Caregiver Allowance 2009 Home care delivery integrated into 9 District Health Authorities 7
Nova Scotia Home Care PP in 2009 Department of Health policy; 9 District Health Authorities deliver. A global budget of $152M for home care in 2006-07: Underclear of budget breakdown to District Health Authorities related to contracted services, program management (i.e., self managed program). Historically public home care contracted with not-for-profit agencies in the delivery of home care. In urban settings for overflow and for specific services for-profit agencies are contracted. Self-managed care program. Non-refundable tax credits. 2006 Continuing Care Strategy. 8
History-New Brunswick Home Care 1979-81 Extra-Mural Hospital (EMH) hospital without walls founded and accepts first clients 1980 Community-based services to seniors through FCS 1991-1993 Extra-Mural partners with FCS in a single entry point (SEP) for persons 65+ and expanded to all regions 1996 Responsibility for Extra-Mural moved to Regional Hospital corporations and becomes a Program (EMP) 1997 Rehab Services moved to EMP 1999 Single Entry Point integrated with Long Term Care Program and expanded to include CBS for adults with disabilities 2002 8 regional health authorities 2005 FCS Policy changes re eligibility and scope 2008 DSD Long Term Care Strategy Source: Cole 2008; Manning 2004 9
New Brunswick Home Care PP in 2009 Home Support delivered via 8 Regions in Dept of Social Development. Distinct from Health Home care - EMP (in Dept of Health and Wellness) connected through the Long Term Care Single Entry Point. Home Support - Most restrictive income testing of 3 provinces assets recently exempt. Public home care have contracts with nfp and fp agencies in the delivery of home care. Clients have option of receiving direct funding to contract services directly. 2008 Long Term Care Strategy. 10
1979-1990 = The first HC policy Public Sector Key= Regional Agencies & the CLSCs = maîtres d oeuvre at the local level + main providers CBOs with PSOC acknowledged 1980s -1990s: emergence a demand side PP = SELF MANAGED CARE Allocation directe / Chèque emploi-service (CES) = a voucher 1996-1998: Social Economy Enterprises Development Creation of a network of 101 EESAD + A Public funding program = PEFSAD = A SE NICHE in Home Support HC 2003-2007 Couillard reform in H&SS = Re-centralization + QuasiMarket mecanisms to manage competition between third sector and Private sector. 2000-2009 = QC Refundable Tax Credits for 70 years & + 1995-2009 = Emergence of non-profit associations for Caregivers = RANQ with 15 members associations 2004-2009: More Acknowledgement + visibility of caregivers 11
Quebec Home Care PP in 2009-Hybrid One Department of H & SS A global budget of 806 M $ in 2005-2006 : 693 M $ (86% of total budget) going to the public sector (95 CSSS in 18 regions) 73 M $ (or 9% of total budget) going to the third sector:or SE 26 M $ (or 3,2% of total budget) going to 500 Voluntary & Community based organizations through the PSOC Program 47 M $ (or 5,8% of total budget) going to 101 EESAD, or SE enterprises in domestic assistance, through the PEFSAD. 75 000 clients. 6000 employees (90%Women). 40 M $ channelled through «Allocation directe» / «Chèque Emploi-service (CES), a voucher used by users to purchase services =DEMAND SIDE PP The Couillard Reform in H & SS structures, the public organizations at regional and local level (ARSSS & CSSS) distinguish their purchasing and their providing roles. Refundable tax credits for persons of 70 years old and more Caregivers: important presence, lack of visibility + acknowledgement 12
QUEBEC NOVA SCOTIA NEW BRUNSWICK Budget $806M in 2005-06 $152M in 2006-07 $133.2M in 200607 % of Health 4 % of Health and SS 5% of Health Care Not available Mandate for Delivery 95 CSSS in 18 H&SS Regional Agencies 9 Health Districts & provincial Continuing Care 7 Regions for Home Support 2 Districts for Health home care User fees for home support User fees for domestic assistance But lower user fees ($4/hr) for clients receiving GIS etc Income test no fees for clients receiving GIS etc Others pay up to $8/hr to a max $400/month. Income-based Maximum 215 HS hours. Assets excluded 13
Family/Friend Caregivers are often invisible and unrecognized but are the foundation of care of older people in the community Public Sector Family/Friend Spouse, children, relatives Social Economy Private/Market friends/neighbours 14
PP to Support Caregivers QUEBEC NOVA SCOTIA NEW BRUNSWICK Mandate of Delivery 95 CSSS in 18 H&SS Regional Agencies (AVQ) 9 Health District & Continuing Care 7 Regions (home support) Program Examples CSSS fund CBO and Voluntary org Respite services Caregiver Allowance Enhanced respite (08) Adult day programs Respite part of hs Subsidizes DayActivity Centres Caregiving Org. CSSS may fund local caregiver org. RANQ (Regroupement des NONE receiving public funds aidant(e)s naturel(el)s du Québec) a network of Public support for Caregiver Nova Scotia to provide information and referral Uses infrastructure to support work of collective caregiver org. Continuing Care Strategy (2006) calls for a Caregiver Strategy Recognition in LTC strategy (2008) Proposed Caregiver Assessment 15 regional/local groups Evidence of Discourse on carers 15
Discussion Is there CO-PRODUCTION? 1. 2. 3. 4. YES. A LOT Is there CO-CONSTRUCTION or Partnership + BILATERAL between State and SE + CBOs? LESS A little in QC in EESAD history: more in 1996 and less in 2009 Less in NS and NB Conditions for CO-C are better in NS with the development of Caregivers not for profit association + social movement Is the Quasi-Market approach (manage competition) increasingly present in provincial HC PP and influencing the relationships between the State & SE? HOW do we see the balance between demand side and supply side in the area of HC PP? 16
Recommendations 1. 2. 3. 4. 5. To acknowledge the presence and the contribution of the Family and Friend Caregivers of the Social Economy and CBOs actors To increase public and collective support to the third sector and informal caregivers and do some bridging To permit the Social Economy Actors (and their networks) and the Family & Friend Caregivers (and their networks) to participate in the DELIBERATION and the CONSTRUCTION of better PP in NB, NS and QC Develop PP in the domain by calling for a «Partnership Governance» rather than for a «Competing of a QuasiMarket Governance» between public, private for profit and Social Economy and CBOs and Informal Caregivers Let us pay attention to local government and Provincial PP as much as to Federal government PP. 17
Cole and Theriault 2009 Vaillancourt and Jetté 2009 Tremblay and Gilbert 2007 Keefe, Glendinning and Fancey 2008 18