Date of Award


Degree Type


Degree Name

Doctor of Philosophy


Health care politics can be understood as a competition among interests for control and power. Traditionally, the medical profession has dominated the health sector because of its monopoly position as the provider of medical services. In Canada, the entrance of government into the medical market as a monopoly purchaser of medical services has challenged the dominant position of the medical profession.;Since the introduction of publicly financed health insurance, politicians and administrators have been concerned with gaining control over the cost of the health care system. A rethinking of the basic policy assumptions has led to efforts to rationalize the delivery of services. This has challenged the professional autonomy of physicians, especially in terms of the fee-for-service method of remuneration and the solo-practice method of organization. As an alternative means of funding and organizing the delivery of primary care, community health centres challenge both of these central aspects of the medical profession.;In Ontario, politicians and administrators have enlisted the support of other interests who might benefit from an alteration of the existing power structure in health care. These interests include corporate rationalist physicians, community-based service providers, local activists and previously repressed consumer interests, such as the poor and otherwise disadvantaged. The purpose of this alliance with other challenging and repressed interests is the desire to overcome the existing bias of the system which favours the entrepreneurial core of organized medicine.;Community health centres have developed as an outcome of the competition among these structural interests in the health sector. The development of community health centres reflects both the extent of the challenge to medical dominance and the ability of coalitions of community activists, representing repressed interests, to develop a local consensus around the introduction of new services within individual communities.;The outcome of the research indicates that the urban policy arena has proved to be a particularly fruitful setting for the alliance of challenging and repressed interests. In the seven case studies presented, the alliance of local activists and corporate rationalists was key to the successful development of CHCs. In the urban setting physicians have been less adept in meeting the challenge to their dominant position than in the provincial or federal policy arenas. However, the cost of the alliance for CHC advocates appears to be an increased propensity for bureaucratic organization at the local level.



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