Bureaucratic Autonomy in Decision-Making for Adding New Oncology Medications to Public Drug Benefit Plans in Canada

Abstract

In Canada, prescription drugs go through a multi-stage process before they are paid for by provincial governments. For oncology drugs, among the most important of these steps are licensing for sale by Health Canada, a non-binding recommendation by the Pan Canadian Oncology Drug Review (PCODR) as to whether provinces should reimburse for the use(s) proposed for the medication, then each province makes a final decision through its own deliberation process. These final provincial deliberations vary in terms of the role granted to the bureaucrats involved. For example, in Alberta the minister of health has the final say on adding and removing drugs from the provincial formulary. In Ontario, the final say, rests with the bureaucrat in charge of the drug benefits programs, the Executive Officer of the Ontario Public Drug Programs. However, even though this bureaucrat formally has full decision-making authority, it will be seen that in fact, the steps leading up to the final decision substantially restrict the Executive Officer’s autonomy and that the position of the Executive Officer’s office within the state, also creates substantial ability for the Minister to indirectly influence him or her, so that there is not much difference between the decision-making structure of the two provinces. This helps to explain why, even though politicians in Ontario have used the delegation of final decision-making authority to the Executive Officer as a blame avoidance strategy, there is no statistically significant difference in the number of uses for oncology drugs receiving a negative evaluation from the PCODR rejected for public reimbursement by the two provinces. The reader should be cautioned that the research presented in this paper is somewhat speculative in nature. Confirming whether these speculations are accurate will require further research involving interviews with participants.