The Royal Commission was an 18-month public inquiry mandated to consult and engage in dialogue with experts, politicians, and citizens on the current state and future potentials of Canada's public health system. The Commission produced 47 recommendations.
Problems and Purpose
In April 2001, the Canadian government established a Royal Commission to deliberate with citizens on the future of healthcare in Canada. The Commission came to be known as the Romanow Commission after the head of the inquiry, Roy Romanow. The Commission took the form of a federal public inquiry with two mandates:
- To gather information and public opinion on the current state and future potential of Canada’s public health care system
- To use the gathered feedback to provide the government with a set of recommendations for changes or improvements to the public health system
Background History and Context
The University of Lethbridge's Mapleleafweb summarizes the key events leading up to the estblishment of the Romanow Commission as follows:
"The Commission on the Future of Health Care in Canada was a federal public inquiry created in April 2001 to review and make recommendations regarding Canada’s public health care system. The Commission, headed by former Saskatchewan premier Roy Romanow, was created by the Chrétien Liberal government as part of the Prime Minister’s pledge to address the long-term sustainability of public health care in Canada."
Organizing, Supporting, and Funding Entities
The Commission was established and funded by the Canadian government, and supported a staff of 35 people. The consultation cost $15 million ($11.4 million USD).
Participant Recruitment and Selection
The Commission encompassed numerous phases and used various methods and tools of engagment, each of which used different forms of recruitment and selection. Many of the public dialogues were open to all, although the 12 Citizens' Dialogues used random selection. According to the final report, many of the consultants used during the first phase of 'fact-finding' were self-selected after the Commission issued a call for submissions. It's unclear whether that call was public or how it was transmitted.
Recruitment for the 21 days of public hearings was conducted via newspaper advertisements calling for the submission of abstracts of proposed submissions. It's unclear what the selection process was for abstracts but for those that were not selected or who did not enter one, an open commenting period was held at the end of each session for additional feedback. Participants could also present their abstracts over the phone which, according to the Commission, would facilitate the participation of those living in remote communities. It is also worth noting that participants were encouraged to write or speak in either official language (English or French) and special arrangements were made for respondents in Nunavut to present in Inuktitut.
Televised forums, workshops held after 9 of the 21 public hearings, and the 3 Regional Forums were attended primarily by experts (except for the workshops). It is assumed that expert participants were selected and invited by the Commission staff based on their qualifications.
Methods and Tools Used
According to the Health Canada website,
"The fact-finding phase included:
- analyzing existing reports on health care;
- identifying knowledge gaps and commissioning independent research from experts to address those gaps and gain new perspectives;
- soliciting and analyzing submissions concerning health care challenges and opportunities from health care providers, stakeholder groups and concerned Canadians; and
- consulting with key health care stakeholders, provincial and territorial governments, and Aboriginal organizations to refine research and consultation priorities.
During the consultation and dialogue phase, the Commission worked collaboratively with a variety of partners to provide Canadians with opportunities to engage in an informed discussion about the future of health care in Canada. Tens of thousands of Canadians — from ordinary citizens to health experts, health ministers and premiers, researchers and health care workers — participated in the process, which included 21 days of public hearings, workshops, policy dialogues, and other consultations."
The 21 days of public hearings were undertaken as part of the fact-finding phase although they overlapped somewhat with the consultation/dialogue phase. For example, "In 9 of the 21 communities in which the Commission held public hearings, expert workshops were organized the day following the hearings. At these sessions, participants were asked to assist the Commission in interpreting the results of both the local Citizens’ Dialogue session as well as the previous day’s public hearings. Participants were also asked to provide advice on the issues of sustainability, access, governance, accountability and quality."
The fact-finding phase also involved 'formal' submissions which were collected through a toll-free telephone line, emails, and written letters. As well, a number of 'informal' submissions — again, from individual Canadians, stakeholder organizations, and advocacy groups — were collected through the same means. The total number of informal submissions was 14,084 with the majority coming via the post.
Six televised forums were held which, according to the final report, "featured health policy experts representing different points of view engaging in a moderated discussion of key health care issues. Each program was followed by an open-line call-in that allowed interested Canadians to question the participants." The forums were broadcast over the Canadian Public Affairs Channel (CPAC).
The 12-session Citizens' Dialogue phase used VViewpoint Learning's Choicework Dialogue methodology. Results of the Dialogue were interpreted by the Commission members, experts, and citizen participants during the 9 workshops and during 3 Regional Forums with experts.
What Went On: Process, Interaction, and Participation
The Romanow Commission’s mandate was to review Canada’s healthcare system, engaging Canadians in a national dialogue on its future and making recommendations to enhance the system’s quality and sustainability. Extensive consultations took place with forty expert reports, nine expert panels, partnerships with broadcasters, universities, business and advocacy groups and the health policy community. The Commission tried to find out Canadians’ views by facilitating 26 public hearings and hosting twelve one-day Citizen’s Dialogues. It sought to go beyond conventional forms of citizen input to one where citizens were encouraged to move from their preconceived understandings and interests to positions informed by careful exchanges of perspectives and reasons. This was real deliberation: engaging citizens and stakeholders in ways that challenged their understandings, confronting them with the sorts of trade-offs called for in health policy.
A full case study on the Citizens' Dialogue component of the Commission is available here.
Influence, Outcomes, and Effects
The consultation process was considered a success overall with the final report of the Commission clarifying Canadian values around healthcare, including demands for transparency and accountability and entrenching an active role for citizens in healthcare policy making. This report devoted a chapter to questions of Indigenous health, yet the deliberative process had not engaged with these groups on any significant or meaningful level.
The Chair of the Standing Senate Committee on Social Affairs, Science and Technology issued a formal response to the Report in December 2002 — the complete text of which is available here.
A year after the Report's submission, Roger Chafe of the Memorial University's Faculty of Medicine wrote an op-Ed which noted that while "it is easy to discount the achievements of the Romanow Commission...[s]till, almost none of its major recommendations have been enacted."
Analysis and Lessons Learned
The Romanow Commission has been considered by some scholars a failure in terms of its engagement with the complex politics of representation. Among those key questions disregarded or not considered were: Who needs to be at the table and in what numbers? Who is typically marginalised in political dialogues? How do dynamics of exclusion and marginalisation get managed within the process? Serious engagement with these politics of representation would have required changes in the structure of the deliberation, challenging the individualistic premises of the ChoiceWorks method.
Research by Citizenship DRC suggests that the successes and shortcomings of the Romanow Commission in including Aboriginal people are tied to three key features of deliberative design. These design choices are critical in enabling marginalised groups to negotiate the complex politics of recognition and representation.
- The extent to which the process is reflexive: how far the participants are allowed to define the terms in which they participate, the issues they address and the form the deliberation takes. If there had been greater reflexivity in the Citizens Dialogues, Aboriginal participants would have been able to deliberate together about the terms of their conversation.
- The extent to which public involvement is iterative: participants being involved from the start. Iterative refers to how much deliberation is treated as ongoing. The Citizen’s Dialogues were single, bounded, eight-hour events, which were non-iterative. Elites decided the structure of the dialogue and how to assimilate outcomes into the commission’s reports.
- The existence of separate spaces: in which members of marginalised groups can reflect on dynamics of power and exclusion and negotiate questions of common agendas, strategies and identities. Separate spaces were not created for marginalised groups yet they allow for culturally specific modes of communication and self-representation; and provide room for the internal complexities of perspectives to be dealt with democratically and deliberatively. They may also allow for a greater reflexivity on how issues are framed.
Choicework Dialogue (method)
Public Hearing (method)
Citizens' Dialogues During the Royal Commission on the Future of Health Care in Canada (component case)
 Makarenko, J. (2007, Apr 1). Romanow Commission on the Future of Health Care: Findings and Recommendations. Mapleleafweb. https://www.mapleleafweb.com/features/romanow-commission-future-health-care-findings-and-recommendations.html#background
 Government of Canada. (2009, Apr 30). Commission on the Future of Health Care in Canada: The Romanow Commission. https://www.canada.ca/en/health-canada/services/health-care-system/commissions-inquiries/federal-commissions-health-care/commission-future-health-care-canada-romanow-commission.html
 Romanow, Roy J. (2002). Building on Values: The Future of Health Care in Canada – Final Report. http://publications.gc.ca/collections/Collection/CP32-85-2002E.pdf
 von Lieres, B and D Kahane (2007) "Inclusion and Representation in Democratic Deliberations: Lessons from Canada's Romanow Commission", in Spaces for Change? The Politics of Particpation in New Democratic Arenas, edited by A Cornwall and V Schattan P Coelho. Zed Books: London.
von Lieres, B. and Kahane, D. "Canada's Designs for Aboriginal Participation." Citizenship DRC Case Study Series.
 Chafe, R. (2003). Romanow one year later: What has been achieved? Nexus online. www.nlma.nl.ca/nexus/issues/winter_2003/articles/article_10.html
Senate Response to the Romanow Report