Mental Health Service Delivery in Ontario, Canada: How Do Policy Legacies Shape Prospects for Reform?

Mental health policy-making in Ontario has a long history of frustrated attempts to move from a hospital and physician-based tradition to a coordinated system with greater emphasis on community-based mental health care. This study examines policy legacies associated with the introduction of psychiatric hospitals in the 1850s and the introduction of public health insurance (medicare) in the 1960s in Ontario; and their effect on subsequent mental health reform initiatives using a qualitative case study approach. Following Pierson (1993) we capture the resource/incentive and interpretive effects of prior policies on three groups of actors: government elites, interests and mass publics. Data is drawn from academic and policy literature, and key informant interviews. The findings suggest that psychiatric hospital policy resulted in important policy legacies which were reinforced by medicare. These legacies explain the traditional difficulty in achieving mental health reform, but are less helpful in explaining recent promising developments that support community-based care. Current reform of the Ontario health system features the introduction of regionalized service delivery and new models of interdisciplinary team-based primary care delivery and presents an opportunity to overcome several of these legacies. The analysis suggests a pressing need to link these two initiatives to overcome system fragmentation.