“Words, whether spoken or written, do things … Texts also circulate: they move around … Words might get repeated and this repetition might increase or decrease their value depending on how they are received” (Ahmed, 2009)
Healthcare organizations convey their identity, purpose and commitment through specific institutional ‘words’ particularly the strategic triangle: mission statements, visions and values that ideally drive institutional decisions and policies. These institutional “words … do things” - perform particular roles and functions (Ahmed, 2009), and portray the institutions’ overall ‘story’: who they are, what they value and where they are going. Part of the institutional story of Canadian healthcare delivery organizations is that healthcare is a ‘right’ (Romanow, 2002) and as such, Canada has committed to universal healthcare coverage (Canada Health Act, 1984) to advance health equity (CSDH, 2008; United Nations, 2015). Further, the Canadian state embraces an inclusive diversity narrative with the adoption of the Multiculturalism Act that “[recognizes] and [promotes] … the cultural and racial diversity of Canadian society and acknowledges the freedom of all members of Canadian society to preserve, enhance and share their cultural heritage” and “[promotes] the full and equitable participation of individuals and communities of all origins” with a commitment to “assist them in the elimination of any barrier to that participation” (Multiculturalism Act, 1985). In addition, as a signing member to the World Health Organization’s constitution, Canada has committed to delivering the “highest attainable standard of health [as a] fundamental [right] of every human being … without distinction of race, religion, political belief, economic or social condition”. With landmark legislation (i.e. Canada Health Act (1984) and the Multiculturalism Act (1985)) and global health commitments, Canada embraces a necessary institutional framework intended to ensure equitable healthcare access and health outcomes for all Canadians; Yet, despite these philosophical commitments, legislation and considerable resources, health disparities persist. In this paper, we report the disjuncture between Canada’s expressed national and global commitments and institutional realities with an analysis of mission statements, values and visions of healthcare delivery organizations in Canada’s most western province of British Columbia. To foreground our findings, we provide a brief overview of health inequities; ideologies that underpin Canada’s universal healthcare; describe the organizational significance of mission, vision and value statements; and present British Columbia’s healthcare structure.
Healthcare Inequities Persist Despite ‘universal’ Health Coverage
Despite the provision of universal health care coverage, healthcare inequity is still evidenced in Canada (Frohlich, Ross & Richmond, 2006; Kennedy & Morgon, 2009; Schoen & Doty, 2004; Lebrun, 2012). There is ample evidence to suggest that healthcare encounters between non-dominant racialized patients and healthcare providers include ‘racial profiling’ (Tator & Henry, 2006; Henry, Tator, Mattis & Rees, 1998) and other forms of racial bias, prejudice and stereotyping that result in health inequality (Tang & Browne, 2008; Adelson, 2005; Frohlich, Ross & Richmond, 2006; O’Neill & O’Neill, 2008; Humphries & van Doorslaer, 2006; Institute of Medicine, 2003; Pardies, Truong & Priest, 2013; Paradies, Priest, Ben, Truong, Gupta, Pieterse, Kelaher & Gee, 2013). These racially discriminatory interactions are not one directional but also experienced by racialized non-dominant healthcare providers in multiple ways, ranging from derogatory racial remarks (Ejaz, Rentscn, Noelkar & Castora-Binkley, 2011; Kirkham, 2013) to being perceived as less competent than European Ancestry healthcare providers (Lo & Bahar, 2013; DasGupta, 2009) and being purposefully excluded from work-related interactions, preferred work sites and promotions (DasGupta, 2009). As a system of power, racism permeates across the everyday movements and interactions of racialized non-dominant individuals stretching across social, cultural, political, economic and spiritual realities. Growing evidence highlights that when people experience inequities including racial discrimination, there is a direct cost to their well-being culminating in illnesses with diminished quality and quantity of life (Krieger, 2012; Schulz et al, 2006; Safaei, 2007; Sondik et al, 2010; Lukachko, Hatzenbuehler & Keyes, 2014; Williams and Mohammed, 2008).
Collectively evaluated, the healthcare experiences of racialized non-dominant patients and healthcare providers narrate a pattern of marginalization and differential treatment; and for patients, this translates to differences in health outcomes. These inequities partly stem from the systemic race dynamics in which Canada, as a nation state, has been established and developed. Canada is founded in the violent and genocidal colonization of Indigenous Peoples which seeded ideologies of white supremacy, privilege and power that have continued to perpetuate denigrating individual, collective, political, cultural and societal racism towards Indigenous communities - culminating in denying Indigenous Peoples their personal and collective sovereignty (Maracle, 1996; Lawrence & Dua, 2005; Alfred, 2009; Coulthard, 2014; Leon, Miller, Gabriel, Sparrow, Webb, Joe, Campbell, James, Planes, Underwood, Thomas & McLeod, 2014). This racial hierarchy has also led to the inferior societal positioning of racialized non-European communities such that European ancestry Canadians (i.e. those who are perceived to be ‘white’) are elevated to the status of ‘Exalted Subjects’ (Thobani, 2007) and constructed as the ‘true’ citizens of Canada. Through rituals of questioning belonging (i.e. ‘where are you really from’), asserting dominance (‘why do they not speak English’) and the classification of non-European ancestry Canadian citizens as ‘visible minorities’ (Thobani, 2007), racialized non-dominant Canadians are understood to be “politically minor players” - reinforcing that they are enduring ‘outsiders’ (Bannerji, 2000, p. 30). These historical and contemporary ideologies related to race reveal the longitudinal influence of Canada’s 1867 founding aspiration to be a ‘White Man’s Country’ (Dua, 2007, p. 446) (Kazimi, 2012) (Wallace, 2017) and contribute to contemporary systemic racism; which privileges dominant racialized communities, while comprehensively and actively subordinating non-dominant individuals and communities. Despite the progressive adoption of Multiculturalism and liberal ideologies, Canada continues to struggle with systemic inequities for racialized communities which translates to differences in quality of life and well-being (Pendakur & Pendakur, 2002; Creese &Wiebe, 2009; Pendakur & Pendakur, 2011; Mikkonen & Raphael, 2010; Ross, Garner, Bernier, Feeny, Kaplan, McFarland, Orpana & Oderkirk, 2012; Bryant, Raphael, Shrecker & Labonte, 2011; Pendakur & Bevelander, 2014) and these ideologies serve as the foundational building blocks of Canadian institutions - including healthcare delivery organizations.
Canada’s Healthcare Vision and Diversity
Canadians “consider equal and timely access to medically necessary health care services” as a basic need and a “right of citizenship, not a privilege of status or wealth” (Ramonow, 2002). Canadian Commissioner Roy J. Romanow’s report: Building on Values: The Future of Health Care in Canada (2002) provided a poignant report on the Canadian health care system, and this report continues to be relevant today − 17 years later. Romanow’s report emphasized the need for quality health care, defined as “delivering the best possible care and achieving the best possible outcomes for people every time they deal with the healthcare system or use its services” (Romanow, 2002, p. 150).
For patients, high quality health care means that their needs and expectations are being met. For health care providers, quality health care means their diagnoses are accurate, they are part of a well-functioning system, and the care they provide is appropriate and effective. For our society as a whole, it means that the overall health of Canadians improves. (Romanow, 2002, p. 150)
Among the recommendations, the report identified that “governments, regional health authorities, and healthcare providers should continue their efforts” to “address the diverse health care needs of Canadians” (Ramanow, 2002, p. 150; recommendation 29, Romanow, 2002, p. 251). This use of ‘diversity’ explicitly includes gender, ethnicity/race, different abilities and newcomer status and plainly acknowledges that “Canada has a diverse population and that diversity should be reflected in Canada’s health care system” (Romanow, 2002, p 155). The report also included input from direct care community organizations recommending that:
… health services should be more culturally sensitive, that health promotion materials should be written in more than the two official languages, and that health care professionals should reflect the diversity of Canadian society and understand the ethnic and cultural backgrounds of the populations they serve (Romanow, 2002, p. 156)
Romanow’s call for cultural sensitivity and equal healthcare access continues to be relevant for racialized non-dominant British Columbians; particularly for healthcare delivery organizations in British Columbia as they serve an ethnically diverse patient population, mirroring the multicultural ethnic diversity across Canada. In response to an ethnically diverse population, British Columbia’s healthcare delivery organizations have incorporated cultural competency training (Kang, Varcoe, Thobani and Reimer-Kirkham, in progress); diversity programs (Kang, Varcoe, Thobani and Reimer-Kirkham, in progress); extensive interpreter and translation services (Provincial Health Services Authority); and specific population programming (e.g. Fraser Health Authority’s South Asian Health Institute, Vancouver Coastal Health’s Aboriginal Wellness Program). The implementation of these policies and programs is often embedded in a culturist framework to explain differences or similarities between ethnic cultural groups (Johnson, Bottorff, Browne, Grewal, Hiliton & Clarke, 2004). When policies and programs are designed based on culturist beliefs, healthcare access, treatment adherence and preventative lifestyle ‘choices’ are often linked to ethnic communities’ lack of language fluency, cultural customs, beliefs and traditions – not the structure of our healthcare system, or the social, political and cultural context of our nation. However, with emerging Canadian research, critical health scholars continue to shed light on how systemic forms of racism play out in healthcare (Browne & Varcoe, 2006; Varcoe, Browne, Wong & Smye, 2009; Reimer Kirkham, 2003; Tang & Browne, 2008; Adelson, 2005; Vukic, Jesty, Mathews & Etowa, 2012) and highlight the impact of the social, cultural and political context in which British Columbia’s healthcare delivery organizations are housed (Varcoe, 2006; Anderson and Reimer-Kirkham, 2002). Critical health researcher, Colleen Varcoe poignantly identifies that anti-racism and equitable praxis operates in the wider world within intersecting historical, social, political “racist context and broader racializing discourses” (Varcoe, 2006, p. 535). Further, critical health researchers extend calls for health equity to include how diversity policies and programs may inadvertently rely on culturist ideals that rely on “hegemonic systems of domination” and “further marginalize those they are intended to include” (Reimer-Kirkham & Anderson, 2002, p. 252).
In summary, race based inequities persist in healthcare despite rhetoric promoting equity. Examining institutional discourse statements reveals how organizational commitments for health equity for non-dominant patients is absent or present in institutional identity. With a focus on British Columbia’s health organizations, our research questions were: 1. How does the public institutional discourse (located in mission statements, values and vision) include diversity and health equity for racialized non-dominant patients, families and communities? 2. How are inclusion and equity discourses constructed in mission statements, values and vision? 3. What are the guiding ‘truths’ that inform these discourses? These analytical processes provide an in-depth analysis of all 8 healthcare organizations’ guiding objectives and ideologies in regards to meeting health equity for racialized non-dominant communities.
Why Focus On Mission, Vision And Value Statements?
Mission, vision and value statements of healthcare delivery organizations narrate their organizational identity, objectives and values. As institutional discourse, the ‘words’ used in these statements convey the cultural, political and societal framework that support current day approaches, programs and initiatives to healthcare delivery in British Columbia, and incorporate strategic priorities set forth by British Columbia’s Ministry of Health. Originally designed to promote a corporate organizations’ “shared expectations amongst employees and communicate a public image … to important stakeholders” (Analoui & Karami, 2002), mission statements also define organizational purpose (Scandura et al, 1996) and goals (Toftoy & Chatterjee, 2004); guide strategic plans (Palmer & Short, 2008), leadership style (Analoui & Karami, 2002) and staff recruitment (Baetz & Bart, 1996); and communicate corporate identity (Leuthesser & Kohli, 1997). In recent years, the nonprofit sector has adopted mission statements as a meaningful technique to communicate core values and activities to stakeholders (Kirk & Nolan, 2010). Healthcare organizations have also embraced the usefulness of mission statements (Grbic, Hafferty & Hafferty, 2013; Ramsey & Miller, 2009; Bart & Hupfer, 2004; Bart & Tabone, 1998; Bolan, 2005) with an emphasis on identifying their purpose (i.e. improving public health), institutional identity, scope of practice, and strategic direction in the mission statement.
Along with the mission statement, many organizations including BC’s healthcare delivery organizations include a vision and list of values. Organizational vision and values parley the institutions’ core ideology and envisioned future (Collins & Porras, 1991, 1997). The vision includes a clear and compelling long-term goal (Khalifa, 2012), a “future destination so strongly appealing that it inspires the wholehearted commitment of all relevant stakeholders” (Bart & Hupfer, 2004, p. 101). The values identify “guiding principles and essential and enduring tenets” (Khalifa, 2012, p. 239) as well as communicate workplace ethic and culture - “attracting and building loyalty among individuals who share and honor the same ethos” (Bart & Hupfer, 2004, p. 101). Collectively, organizational culture is confirmed through these types of institutional discourse statements to communicate “management beliefs, perspectives and approaches … to employees and stakeholders [patients and families]” (Babnik, Breznik & Dermol, 2013, p. 613) as well as share the broader cultural context: a “view of the physical, political and social environment in which an institution is embedded” (Grbic, Hafferty & Hafferty, 2013, p. 852). Analyzing these institutional discourse statements offers an understanding of organizational culture and ethos that drives the delivery of British Columbia’s ‘universal’ healthcare commitment and possible disjunctures from the principles of accessibility and universality that affirm “the conviction of Canadians that essential health care services must be available to all Canadians on the basis of need and need alone” (Romanow, 2002, p. 61).
Project Context: British Columbia’s Healthcare System
Located on the Western coast of Canada, the province of British Columbia is home to approximately 4.4 million peopleand has a budget of 18.8 billion dollars to publically administer, comprehensive, universal, portable and accessible health care in accordance with the Canada Health Act (Canada Health Act, 1985). While British Columbia’s Ministry of Health is responsible to “[ensure] that quality, appropriate, cost effective and timely health services are available for all British Columbians”, five provincial health authorities (Fraser Health Authority, Interior Health Authority, Northern Health Authority, Vancouver Coastal Health Authority, and Vancouver Island Health Authority) provide direct health care delivery (Ministry of Health 2016/12-2018/19 Service Plan, February 2016). Additionally, the Provincial Health Services Authority collaborates with the 5 provincial health authorities to provide specialized province-wide health services such as cardiac and stroke services, oversees BC Ambulance Service and Patient Transfer Network, as well as operates specialized health centers (e.g. BC Children’s Hospital and BC Cancer agencies) . In coordination with the Ministry of Health, Vancouver Coastal Health Authority and Provincial Health Services Health Authority, Providence Health Care also operates in the Greater Vancouver Area to provide specialized care through 14 healthcare facilities inspired by 5 different congregations of Catholic Sisters. In many ways, Providence Health performs similarly to the other Health Authorities but receives horizontal governance and support from Vancouver Coastal Health (e.g. Vancouver Coastal Health’s Aboriginal Wellness program supports Providence Health when needed). Further, the first province-wide health authority in Canada to focus on Canada’s Indigenous patients, families and communities: the First Nations Health Authority is dedicated to improving the “health and well-being of BC’s First Nations and Aboriginal people”. It is important to note that their “work does not replace the role or services of the Ministry of Health and Regional Health Authorities” but instead FNHA “[collaborates], [coordinates], and [integrates] … respective health programs and services to achieve better health outcomes for BC’s First Nations”.
Similar to other formalized, government-directed healthcare bodies, British Columbia’s healthcare delivery organizations (HDOs) are structured institutions shaped by federal and provincial leadership, policies and mandates with multiple levels of governance and leadership (e.g. Board of Directors, Senior Leadership, Directors) and accountability platforms (e.g. report cards, strategic directions). Each healthcare delivery organization has a unique leadership team which designs the organizational processes and systems in response to federal and provincial mandates, specific direct care health delivery needs and patient populations. These guiding directives ideally would be reflected in institutional identity, purpose, core values, strategic direction and scope of care through publically shared institutional discourse (e.g. mission statements, values and visions).