Government Structure and Equity in Access to Psychotherapy: A Study of Canada, with Comparisons to Australia and the United Kingdom

Gaps in mental health funding and insurance coverage have resulted in significant unmet need and inequities in access.Both Australia and the United Kingdom have expanded public funding for psychotherapy over the past decade, and it remains to be seen how far the new federal transfer of $5 billion over ten years will go toward improving equity in access in Canada.This four-paper dissertation examines how the exclusion of psychotherapy came about in Canada and why it has persisted, the extent to which access currently depends on how rich or poor you are, and what could be done to change this in the Canadian context in light of lessons learned from Australia and the United Kingdom.The first paper analyses parliamentary debates to trace the role of Canada's decentralized government structure in constraining federal transfers.The evidence suggests that Canada's decentralized form of government has been at the heart of its inability thus far to introduce significant reforms.The primary contribution of other factors (such as stigma and cost) has been their influence over whether or not mental health has been enough of a national priority to warrant the use of federal spending power.The second and third papers are large-N studies using data from Canadian and Australian population health surveys to measure the extent to which access to psychotherapy and other mental health services varies by income.Income-based inequities in utilization and unmet need are found to be significant problems in Canada, particularly for psychologist services.In Australia, inequities in utilization are found to be less of a concern than in Canada, but unmet need for psychotherapy is more inequitable, suggesting a possible backlog effect with the expansion of public funding in 2006.The fourth paper uses interviews with key informants in Australia, the United Kingdom and Canada to delve more deeply into the relationship between government structure, service system design and equity in access to psychotherapy.The key finding is that while more centralized governments have greater capacity for reform, achieving equity in access requires explicit focus regardless of government structure, service system design or social insurance model.Writing a dissertation is a rather solitary endeavour and I could not have done it without support and encouragement from many quarters.First, I would like to thank my dissertation committee members: Allan Maslove, for his steady encouragement and insightful guidance from our first discussion to the completion of this dissertation; Jennifer Stewart, for inspiring the inequity research and for her invaluable assistance in puzzling it all through; and Vandna Bhatia, for strengthening the dissertation's approach to theory and for her excellent editorial suggestions.Thanks are also due to Saul Schwartz, for getting me off to a good start by asking so many fundamental questions during the proposal stage.This dissertation had its genesis in my work with the Mental Health Strategy team at the Mental Health Commission of Canada between 2008 and 2012.By focusing this dissertation on government structure and equity in access to psychotherapy, I was able to bring together policy questions from my earlier career as a family therapist with a deep curiosity about the role of jurisdictional dynamics in mental health policy.The mentors, friends and colleagues I was fortunate enough to work with at that time have continued to support and challenge my development as a researcher throughout the dissertation journey:

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