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Pharmaceutical programs and social policy development: comparing Canada, Australia and the UK Boothe, Katherine


Canada is the only OECD country that provides broad public health benefits but lacks a universal, nation-wide system for funding prescription drugs. This puzzle cannot be explained by the literature on national health insurance, which suggests that the tendency to consider all health services as a single policy has missed an important source of cross-national variation. How can we explain the lack of a major pharmaceutical program in Canada, in light of the country’s own extensive health system and the experience of almost all other welfare states? More generally, why do some countries adopt universal, comprehensive pharmaceutical programs, while others do not? To answer these questions, the study compares Canada to the UK and Australia using a process-tracing approach, and finds that the range of services in a country’s public health system is determined by the earliest decisions about how to approach policy development. Where institutional, ideological and electoral conditions allowed for large-scale change and all services were introduced simultaneously, countries tended to maintain the full scope of services. But where institutional barriers, ideological dissensus and low issue salience made radical change difficult, health programs were introduced incrementally, and policy development tended to stall after the first priority. Although incrementalism was initially less politically risky, it was also inherently limiting. Barriers to the introduction of services increased over time, and services that were initially lower priorities (such as pharmaceuticals in Canada) were pushed off the public agenda. In investigating this phenomenon, I provide specific mechanisms by which a more limited “path” of policy development becomes “dependent,” and argue that we must consider not only the role of ideas in policy making, but also the role of ideas over time. The study also investigates the implications of the approach to policy development for subsequent policy outcomes. It finds that factors that support the simultaneous adoption of a full range of health services also make it more difficult to retrench these services later on.

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