Presentation Dr Stephen Tomblin Panel Joan Dawe  Dr. David Dibbon  Kelly Vodden

1. A Dialogue on Social Innovation:Regional Approach to Governance in Health, Education, Municipal Government and Economic Development MEMORIAL PRESENTS Presentation Dr Stephen Tomblin Panel Joan Dawe  Dr. David Dibbon  Kelly Vodden

2. Managing Change Through Regionalization:Lessons from Newfoundland and Labrador MEMORIAL PRESENTS Dr. Stephen Tomblin Department of Political Science and Faculty of Community Medicine Memorial University of Newfoundland October 6, 2005

3. Focus on regionalization reform in four policy fields: Education Health Care Economic Development Municipal Government OUTLINE: What is regionalization? Why regionalize? Examples from Newfoundland and Labrador Similarities across policy fields Differences across policy fields Policy lessons Managing Change Through Regionalization: Lessons from Newfoundland and Labrador

4. What is regionalization? • About delivery and decision making for programs and services at “regional” level • For this discussion: about regions within the province • Innovation / change driven by idea that old ideas, institutions, processes are out of touch and must be replaced: • incrementally over time or • quickly through a “big bang”

5. Irony that centralization and consolidation of power can and does often occur with regionalization The number of opportunities for citizen participation have actually been curtailed through the centralization of various services delivered by boards or authorities (School Boards; REDBs, RIHAs) Explains some of the resistance to regionalization Regionalization not necessarily Decentralization

6. Why Regionalize? Policy goals to: • reduce costs • respond better to the needs of local populations • increase local control over decision-making • coordinate and integrate services • achieve efficiencies in resource allocation • improve access to services • manage institutions effectively • increase accountability • achieve improved outcomes

7. Why Regionalization?Democracy and Citizen Participation • devolution of powers by provincial governments • potential to allow lay persons opportunities to participate in decision-making and tailor decisions to the specific needs of local communities • citizen participation can be problematic: • requires specialized knowledge that most citizens do not possess • creating more voices and diversity makes it more difficult to build common vision for the province • regionalization experiments may work at cross-purposes • may be ploy for avoiding blame for cutting public services • rural communities lack capacity and volunteers • lack of capacity can result in cynicism and apathy

8. Why Regionalization?Appointment vs. Election • Appointed bodies are much more common than elected • allows the provincial government to exercise more control over the process of regionalization • provides opportunity to ensure there is a balanced approach to representation and key stakeholders are involved in the process • allows government to reward friends • Main disadvantage with appointed boards is the lack of legitimacy and accountability to citizens’ interests • stakeholders may (through their actions in the process) undermine reforms and defend the status quo • where elections do occur (eg. school boards in NL), turnout and interest are low • Health Authority elections in other provinces have not generated much citizen interest either

9. Building new forms of innovation is never a smooth process Requires: • Mobilizing a new vision • Leadership • Mobilizing a coalition and public support around the new regime • Finding the means to tackle and rethink old ways of doing things • Getting the new vision institutionalized • either bring in or replace old institutions and interests

10. Lessons from Newfoundland and Labrador:Regionalization and Education • Education reform driven by two factors: • adapting to the needs of a “post-industrial” society • reduce or eliminate the power of the churches to control the education system • New vision from two Royal Commission documents: Building On Our Strengths and Education for Self-Reliance (1986) • upgrade “human capital” with training that was scientific and entrepreneurial • education viewed as a key to economic development • Royal Commission Report, Our Children, Our Future (1990-92) focused on the delivery and organization of education in NL • stated that “the denominational system in its present form creates divisiveness and is an impediment to social cohesion.”

11. Regionalization and Education:Not a Smooth Process • Negotiations between the province and churches were launched in 1992 • Agreement could not be reached • Government decided to seek public approval to amend Term 17 via referendum • 1995 referendum called for government to retain denominational education but to allow for the reduction in the number of school boards from 27 to 10 • majority of voters (55%) endorsed the amendment • boards would be elected • However, new amendment was confusing as it permitted both uni-denominational and inter-denominational schools.

12. Regionalization and Education: “Big Bang” • 1997 second referendum to remove all denominational control over education in NL • turnout of 53%, 73% of voters approved amendment to Term 17 • 2004: further consolidation in the number of school boards from 11 into five • Rationale based on declining enrolments and attempts to create administrative and managerial efficiencies • However, new regional entities were larger and no public input was sought by government (new Eastern School Board has 127 schools with approximately 44,000 students distributed across the Avalon, Bonavista and Burin peninsulas)

13. Regionalization and Economic Development • Fall 1990: process leading to the province’s first strategic economic plan began with Economic Recovery Commission (ERC) • 15 public meetings, 15 formal presentation meetings, five regional roundtables, a pan-provincial roundtable and 261 written submissions • key feature of the Strategic Economic Plan was plan to establish 17 economic zones across Newfoundland and Labrador • Jan. 1995: Report of the Task Force on Community Economic Development • Equal federal – provincial and community organization representation on Task Force • Call for Regional Economic Development Boards (REDBs) in 18 (later 20) economic zones • Federal and Provincial adoption of recommendations • REDBs not appointed by government • Strategic Economic Plans to establish shared priorities for development

14. Why the creation of economic zones? • each region is better able to participate in and respond to opportunities for economic growth • better coordination and integration of economic planning • citizen input in developing economic plans for each zone • joint projects can be undertaken by zonal communities • major centres in each zone will have infrastructure improved to attract new services and investments • greater regionalization of government administration • the unique characteristics of each region will be easier to identify and will be better understood

15. Regionalization of Health Care • 1990: comprehensive health restructuring began • Wells government established a Resource Committee to review the state of the health system; included key stakeholders • National Health Ministers conference, regionalization emerged as a potential solution to combat escalating hospital costs (everywhere but Ontario). • province adopted several strategies for combating rising expenditures: • regionalization • focus on the population health model • integrated approach to health care delivery • shift from hospital to community level care.

16. Regionalization of Health Care • Advantages associated with regionalization: • reduction in costs due to economies of scale • increases in quality of care, due to improved potential to attract specialists • greater justification for specialized administrative services (increased capacity), such as data handling, and in-service education • Disadvantages of regionalized health system: • diminished community involvement • potential for closing institutions in rural and remote areas • possible decline in employment

17. Regionalization of Health Care • March, 1993: Report on the Reduction of Hospital Boards • consultations held across the province • ten recommendations for government; most were formally adopted • 14 regional health authorities established: two integrated authorities, four community health boards, six institutional boards and two boards overseeing nursing homes and the NL Cancer Centre • appointed boards

18. Regionalization and Municipal Government • amalgamation debate due to small population that is highly dispersed • most municipalities still consist of small communities that are isolated from one another • 1997 Task Force on Regionalization • conducted interviews and seminars with municipal officials and the public throughout the province • need for regionalization and the sharing of services • However, the public was not very supportive: “overwhelming response was one of ‘go away, leave us alone, we’re already doing the best we can to share with our neighbours.’”

19. Regionalization and Municipal Government • One example of regional cooperation is the Avalon Waste project • ambitious effort with the goal of merging 43 disposal sites into one location • new waste site would cover the Avalon peninsula up to Clarenville

20. Similarities and Differences in Reforms Across Policy Fields Similarities • Reducing costs for services • Reducing levels of management and administration for services • Achieving efficiencies through centralization • Claims of responding better to local and community needs • Improvements in services provided and access

21. Similarities and Differences in Reforms Across Policy Fields Key Differences • Frameworks, Concepts and Objectives relied upon to define vision and strategies: • equity (health needs-based) • efficiency- based vision more dominant in economic development field • Selection of members for regional boards: in NL, most are appointed, not elected • Consultations: regionalization has been established with varying degrees of public input • Success of reforms: in health, positive perception but in education, municipal government more challenges and constraints

22. Policy Lessons Points to Consider: • Regionalization adopted during times of crisis, whether fiscal, social or political • Ideas for reform came from external and internal sources • Requires public buy-in or support • Regionalization absolves responsibility for government to make the hard decisions but allows a more community-based approach to problem definition and solution.

23. Policy Lessons • Regionalization adopted in some cases without widespread public input and consultation • Lack of meaningful community participation • Little policy learning across regional systems • More recently, regionalization imposed from top down, from centre to periphery in education and health

25. A Dialogue on Social Innovation:Regional approaches to governance in health, education,municipal government and economic development MEMORIAL PRESENTS Joan Dawe Chair Eastern Regional Integrated Health Authority October 6, 2005

26. New Directions for Health and Community Services • September 10th, 2004 press release announcing restructuring: • “Creating fewer, more accountable health authorities is a necessary step in renewing our health and community services system and meeting client needs. Fewer regions mean less administration and more opportunity for collaboration. Integrated boards will have the ability to focus on the full continuum of care, from community care to acute care and long-term care, resulting in better service for clients.”Minister of Health and Community Services

27. Four New RIHA Population • Eastern 295,000 • Central 100,926 • Western 82,034 • Labrador 40,516

28. Eastern Health -Organization Former Boards: • Avalon Health Care Institutions Board • Health & Community Services - Eastern • Health & Community Services - St. John’s • Health Care Corporation of St. John’s • Newfoundland Cancer Treatment and Research Foundation • Peninsulas Health Care Corporation • St. John’s Nursing Home Board

29. Mandate • Broadest Level • Service 2. Education 3. Research Regional Mandate • Full continuum of community, institutional acute and long term care Provincial Mandate • Adult tertiary care • Child specialty services • Cancer care • Genetics program • Mental Health

30. EasternHealth - Organization • 18 member (volunteer) appointed Board • $850 m. operating budget • 12,000 employees • 27 health care facilities • 30 community offices

31. Population Health • Key concept and approach for program and policy development aimed at improving the health of the population. • Elements: • Addresses the determinants of health and their interaction; • Base decisions on evidence; • Increase upstream investments; • Apply multiple strategies; • Collaborate across sectors and levels; • Employ mechanisms for public involvement; • Demonstrate accountability for health outcomes.

32. Challenges • Creating new organizational culture. • Maintaining stability throughout reorganization. • Very large geographic area. • Urban / Rural issues. • Competing demands for services and infrastructure –community / institutional acute care / long term care. • Human and fiscal resources.

33. Opportunities • Promote population health approach • Achieve better balance between promoting health / preventing illness / care and treatment • Build an integrated, seamless health and community services system • Improve access to services • Address gaps through reallocation of resources • Avoid unnecessary duplication of services.

34. Governance Legislation: Regional Health Authorities Act (proposed) Transparency and Accountability Act(assent Dec. 16, 2004) Policy Governance Model

37. A Dialogue on Social Innovation:Regional approaches to governance in health, education,municipal government and economic development MEMORIAL PRESENTS Dr. David Dibbon Faculty of Education Memorial University of Newfoundland October 6, 2005

38. Newfoundland and Labrador School Districts 2004-2005 Eastern • Schools 125 • Pupils 45,258 • Teachers 3,000.7 • Labrador • Schools 16 • Pupils 4,505 • Teachers 343.3 • Nova Central • Schools 75 • Pupils 14,741 • Teachers 1,099.5 • Conseil scolaire • francophone • Schools 5 • Pupils 193 • Teachers 31.8 • Western • Schools 82 • Pupils 14,742 • Teachers 1,159.1

39. Regionalization in Education Though pupil enrolment numbers have been declining, the number of school board districts and administration staff has remained constant. We will reduce the number of school boards by September of this year from eleven to five, for an anticipated savings of about $6 million annually (Budget 2004).

40. Governance in an era of mandated change You can’t mandate what matters, but Mandates can work if they are supported

41. Regionalization means many changes masquerading as a single change

42. The Impact of Regionalization • On the education system • On district office • School administrators • Teachers • Students

44. Regionalization • Myths • Big is better • More efficient = more effective • It is possible to do more with less • Downsizing to prosperity • Shared vision • Realities • Era of fiscal restraint • Top down model of DM • Loss of capacity • De-professionalizing • Rational is not always best • Opportunities • New model of governance • To adequately resource the system • To involve the community

45. It is only when responsibility for education is shared by the community can education ever be reformed ( Dewey 1952).

47. A Dialogue on Social Innovation:Regional approaches to governance in health, education,municipal government and economic development MEMORIAL PRESENTS Kelly Vodden Dept. of Geography, Center for Sustainable Community Development Simon Fraser University October 6, 2005

48. 1995 • Strategic economic planning • Coordinating business support • Supporting communities and organizations • Coordinating social and economic initiatives • Public education and participation

49. 1998 • SSP implementation • coordinated approach tosocial and economic development • building and supporting community involvement, action and partnerships • input into policy and decision-making

50. 2005 • focal point for partnerships with government • rural voice • support for communities and regions • develop regional approaches that link economic, social, cultural and environmental issues