Canada's health care, which comprises a myriad of institutions and practices, is often referred to as Canada's best-loved social programme. This support is not surprising, given that it has been one of the most accessible health care systems in the world and has played a significant role in prolonging the life of many Canadians. In recent years, however, it has come under attack from a variety of sources. Every jurisdiction in the country has initiated far-ranging reforms aimed at reducing costs and has introduced strategies developed for lean and mead production in the private sector. Continuing cost cutting measures and the resulting dismantling of the country's health care programs have seen a vast number of hospital beds closed, drugs delisted, services privatized, average ages for admission to long-term care facilities raised, fees charged, waiting lists and waiting times extended, and day surgery and out-patient clinics expanded. More responsibility has been shifted to the 'community' and to family members, where women in particular are expected to administer treatments and to provide care without the structures, expertise, and resources they need. Meanwhile, in the labour forces tens of thousands of health-care providers face deteriorating terms and conditions of employment, despite the effects on their health care or on the health of those they serve. Wasting Away examines how many of these reforms fail to address the fundamental problems in the system. Many of the provincial reports justified cutbacks by agreeing with the critics of the system that the focus should be on health, rather than illness, and that health is determined not only by individual lifestyles but also by social conditions. With such an approach, it could be argued that part of the solution to rising costs is prevention and another part is to send care, in the words of one report, "closer to home". Although there is talk of "client-oriented" care, total quality improvement, employee empowerment and community support, reform has primarily meant less of the same within institutions and more unpaid work for women in the home. The basic problems with institutional care remain largely untouched or even exaggerated while fewer and fewer people have access to good care.

1. The Wasting Away of Care 1.1. The Invisible Hand 1.2. The Origins of the Book 1.3. The Sources: Interviews, Participation, and Documentary Evidence 1.4. The Guiding Theory 1.5. The Book in Outline 2. From Cuts and Chemicals to Carrots and Condoms: The Development of Canadian Health Care 2.1. Defining Health 2.2. Determining Health 2.3. Government Responsibilities 2.4. The Basic Assumptions of Canadian Health Care Delivery 2.5. Challenging the Assumptions 2.6. Conclusion 3. Who Provides: The Institutions 3.1. Hospitals: The Core of Allopathic Medicine 3.2. Sharing the Risks 3.3. Cutting Back on Care 3.4. Residential Care Facilities 3.5. Conclusion 4. Who Provides: The People 4.1. Developing the Health Care Workforce 4.2. What Counts Is What Can Be Counted: Measuring Out Care 4.3. The 90-Second Minute: Total Quality Management 4.4. Patient-Focused Care: Re-engineering Care 4.5. Community Care 4.6. Conclusion 5. Who Pays 5.1. The Historical Context 5.2. Funding Care 5.3. The Impact of Care 5.4. The Costs of Care 5.5. Cutting Costs: Who Pays and Who Profits 5.6. Conclusion 6. Who Decides 6.1. Public Decisions 6.2. Private Provision 6.3. Worker Control 6.4. Patients' Rights 6.5. Conclusion 7. Who Wins and Who Loses

Pat Armstrong , CHSRF/CIHR Chair, Heath Services and Nursing Research, York University, Canada, Hugh Armstrong , Professor, School of Social Work, Carleton University, Canada

"... worthwhile reading for all participants in the system, including those in charge of allocating money, administrators and all providers and recipients of services." Canadian Medical Assoc. Journal (December 1996)