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...ignored, or subsumed (Armstrong & Armstrong, 1999; Bernier & Dallaire, 1999; Fuller, 1999; Gurevich, 1999; Howard & Willson, 1999; Rosser, 1994). The purpose of this qualitative research study was to gain insights into the perceptions of rural women on the impact of health reform in Saskatchewan and Manitoba. This paper considers preliminary findings of the perceptions of individual and communities of Saskatchewan rural women regarding health reform/renewal policy in an effort to provide a broader perspective on the impacts and implications of that province's health reform directions. By identifying the perceptions and opinions of rural women, this research potentially contributes to rural women's understanding of health policy and may encourage them to become more directly engaged in future health policy making and planning.
Keywords: Reform, Rural Women, Saskatchewan Health Care, Health Policy
INTRODUCTION
Health policy is often developed, implemented, and evaluated with minimal consideration of the impact (real or perceived) and implications for individuals, groups, and communities involved. In recent years, health reform or health renewal has become an increasingly debated and scrutinized health policy agenda. Much of the ensuing health policy research focuses on economic, fiscal, and political motivations and consequences of this policy direction. In light of the rapid progression of health reform initiatives nationally and internationally, there is an increased need to consider the meaning and implications of such health policy decisions to various sectors of the population beyond these traditional indicators.
According to Torrance (1987), changes in the health system tend to mirror changes in Canadian society (i.e., a shift to urban, decentralization, and individualization). Baumgart and Larsen (1992) added to the list of challenges to the health system with issues of emergent diseases, increasing morbidity rates, cultural diversity, and household composition (i.e., single person households, one parent families). Collier (1993) stated that "rural areas and people are still subject to decisions made far away in the economic and political centres. Rural people are still separated from these centres by important differences in ways of living, being, seeing, and thinking" (p. xvii). It is therefore critical to recognize this context within which rural residents interface with health reform policy.
Of specific concern is the lack of a consideration of the issues and needs of rural women beyond traditional biomedical health care. In fact, women's experiences with health restructuring have been largely overlooked, ignored, or subsumed (Armstrong & Armstrong, 1999; Bernier & Dallaire, 1999; Fuller, 1999; Gurevich, 1999; Howard & Willson, 1999; Rosser, 1994). Rural women constitute a unique segment of the population affected by change in health care services available in their local communities. The impact of change may be reflected in the role of substitute care provider, job loss (due to nursing jobs and health care support jobs being primarily female occupied), and increased fear for safety and health status of family and community. Walters (1987) stated that "if (health) policy is to reflect women's priorities, it is critical that women collectively assert their concerns and establish structures for their discovery and articulation" (p. 322). According to the Women's Health Clinic of Manitoba (1998), "it is imperative for women to have a voice in the (health sector) change and any subsequent decision-making structure(s) which would evolve from the reform process" (p. 8).
This paper considers preliminary findings of a research study, the purpose of which is to articulate the level and type of impact of health reform/renewal policy on select rural women in Saskatchewan from their perspectives. The rationale for the specific consideration of women emanated from the potential for multiple roles and challenges experienced by rural women in the reconfiguring health care system. This paper reflects a subset of a study considering this issue and further comparisons with rural Saskatchewan and Manitoba women regarding health reform policy implications.
SASKATCHEWAN CONTEXT
Over the past decade, rapid and significant changes in health care delivery, technology, and public expectations have challenged Canadian and provincial governments to re-construct a health care system which balances current and future political, legal, economic, and social realities. For many involved, health restructuring has remained an amorphous, resource consuming policy approach. To most Canadian consumers of health service, it has meant exposure to a new order and emphasis within health care from treatment towards prevention and promotion; from universality to sustainability. For the residents of Saskatchewan, health care reform/renewal has meant significant redistribution of organizational entities through regionalization/district formation, uncertainties in terms of service/facility continuance, and decentralization of power.
In 1992, the government of Saskatchewan introduced health reform/renewal with the abject objectives of introducing a wellness (non-treatment oriented) philosophy for health services and enhancing the individual communities' control of health care delivery, including devolution of authority to partially elected district health boards. It created the mechanism for formation of health districts with expansive planning, capital, operational, and administrative roles and responsibilities for most aspects of health care services in the province. In addition to dissolution of more than 400 previous health care service boards, the initial phases of health reform/renewal in Saskatchewan entailed closure or conversion of 52 small, primarily rural hospitals and establishment of 32 geographically defined districts.
For some women of rural Saskatchewan, health reform/renewal was yet another policy decision impacting on the economic, demographic, and resource sustainability of "small town" Saskatchewan, the rural "family," and the "rural" individual. Consideration of the consequences for rural women of restructuring of health service delivery and redistribution of resources under the policy is critical for individuals who are already overburdened, multi-tasking, economically marginalized, and laden with socially constructed roles and responsibilities. So, how have the women in rural Saskatchewan communities fared in the implementation of the health renewal/reform policy agenda? Further, what does this perspective mean for future public policy changes in rural Saskatchewan?
DESIGN
The research study employed a multiple case study approach appropriately "investigating a contemporary phenomenon within its real-life...
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