Using The "3-I" Framework to Analyze Ontario's Long-Term Care Homes System
Ontario's fragmented, privatized LTC system reflects historical exclusions and neoliberal priorities, burdening seniors and caregivers.
Introduction
By 2040, Ontario’s 80+ population is expected to double, with one in five individuals requiring round-the-clock care due to complex needs [1]. With a rapidly aging population, more Canadians are relying on long-term care (LTC) homes (also known as continuing care facilities, nursing homes, and residential care homes) to receive personal and health care services for their daily living [2]. More than 45,000 seniors are waiting for long-term care, and this waitlist has doubled over the past decade and is projected to grow, adding 1,000 people annually [2]. Moreover, changemakers have overlooked the objections of caregivers in terms of a continuum of care. In Ontario, LTC homes are funded by the provincial government and operated by municipalities, not-for-profit organizations, and for-profit organizations, making it a shared responsibility across actors [3].
The “3-i” framework is a theoretical instrument that helps to understand and influence the policymaking process [4]. The framework describes the three common factors that can explain the public policy development process. It suggests that policy development and its choices include the interests and ideas of actors and the institutions that govern that policy area [4]. This informative article will critically examine the policy landscape of LTC homes in Ontario by using the 3i framework to analyze the relevant institutions, interests, and ideas that influence policies around LTC.
Photograph by Sabine van Erp
Institutions
Institutions are the organizational factors, formal and informal rules, and norms that construct political behaviour. Institutions are the policy legacies and government structures that actively shape a policy area [4]. LTC does not fall under the Canada Health Act (1984) for publicly funded health insurance [5]. The Act considers LTC as an “extended healthcare service” which exempts it from being insured. Although the federal government provides funding to the provinces and territories for healthcare through Canada Health Transfers, there is no specific funding for LTC. Instead, it is up to each jurisdiction to allocate the general funding as necessary [5].
“LTC homes are funded by the provincial government and operative by municipalities, not-for-profit organizations, and for-profit organizations making it a shared responsibility across actors.”
In Ontario, the Ministry of Long-Term Care oversees the licensing and regulation of LTC homes [3]. The Ministry is responsible for supporting the development of new homes and setting regulations, legislations, and policies to create a standard that all owners (public, for-profit, not-for-profit) must abide by [3].
Interests
Interests are the agendas of actors and stakeholders and their desire to influence the policy process to satisfy their goals. In Ontario, The Minister of Long-Term Care is at the forefront of allocating funding, administration, and setting legislation and regulations on LTC homes in Ontario [6]. They can influence the LTC policy landscape of Ontario and have the resources and ability to act on the policy agenda. In Ontario, 16% of LTC homes are publicly owned (municipal government) while 84% are owned by private organizations (57% for-profit and 27% not-for-profit) [2]. Private organizations have a large stake in policies in the LTC area, including an economic interest [1]. The current neoliberal policies allow private organizations to thrive under the current LTC policy decisions as they own most of the LTC homes in Ontario. LTC is seen as a responsibility outside of the provincial government, allowing room for privatization of this service [1].
“The current neoliberal policies allow private organizations to thrive under the current LTC policy decisions as they own most of the LTC homes in Ontario.”
A 2023 survey found that 3 in 4 caregivers worry that they cannot handle their duties, and 42% of them reported experiencing distress due to their caregiver role [1]. Family and caregivers are concerned with the long wait times to get into LTC homes and whether their loved ones will be eligible to be admitted, as the provincial government has restricted the eligibility criteria over the years [1].
Moreover, with over 100,000 LTC staff including Registered Nurses and Personal Support Workers, the Ontario Nurses’ Association (ONA) has expressed a deep concern regarding large amounts of public funds going toward the private shareholders of LTC homes leading to a staffing shortage in publicly owned LTC homes [1, 7].
Ideas
Ideas are the knowledge and values that influence how different actors or interest groups define a policy problem and in turn, perceive policy options [4]. In Ontario, the question of who should be responsible for taking care of the elderly population continues to be neglected [8]. Some believe the government should play a central role in ensuring high-quality, affordable care for seniors by mandating LTC services as medically necessary and therefore an insured service. Others prioritize ideas of individual responsibility [8]. This disagreement on senior care has created a policy landscape that puts the responsibility on seniors to care for their health and well-being.
Canadians often take pride in Canada’s “universal health care” also known as Medicare [5]. However, the importance of LTC for seniors is not reflected in Canadian legislation or the healthcare system. Molinari and Pratt suggest that eldercare is arguably the least valued of all forms of health care as it is devalued in neoliberal societies where seniors are viewed as unproductive members who burden the healthcare system [9]. This opens the policy window for options that favour ideas of privatization and capitalism of LTC services and keep senior care away from the public eye.
“This disagreement on senior care has created a policy landscape that puts the responsibility on seniors to care for their health and well-being.”
For instance, Ontario introduced the Connecting Care Act (2019) which required a multi-year accountability agreement between Ontario Health and the Ministry of Health to provide funding to the private sector to build and update LTC homes [7]. This accelerated the privatization of the LTC sector and threatened the job security of care workers and the out-of-pocket affordability plans of residents [7]. Now, LTC homes in Ontario are governed by the Fixing Long-Term Care Act (2021) which sets out the terms and conditions LTC homeowners must abide by to receive provincial funding [11]. This offloading of senior care responsibility over to the private sector through government regulations and legislation has given rise to privatization and public underinvestment in LTC homes [9].
COVID-19 Pandemic
In 2019, the Ontario government split the Ministry of Health and Long-Term Care into two ministries – the Ministry of Health and the Ministry of Long-Term Care [11]. Both ministries continue to collaborate to address larger healthcare issues such as senior's access to LTC services and supporting health human resources [11]. This policy decision led seniors and their caregivers to face the COVID-19 pandemic with a new ministry with many moving priorities [12]. Like other nations, Canadian provinces further isolated seniors during the pandemic by enacting and updating visitation policies and restricting their daily activities [8]. This caused a global uproar as social connections, especially with family and friends are imperative to the overall quality of life for seniors [8].
Power configurations & contentious issues
Ageism is a reality in Canadian society plagued by prejudice and negative beliefs about seniors. Public authorities, including elected officials, often perpetuate ideas of seniors as being a burden to the healthcare system which often leads the public to view the deaths of seniors as insignificant and expected [12]. Ontario experienced the second-highest number of LTC resident deaths during the pandemic [8]. With the onset of the pandemic, the Ontario government began enacting and updating visitation policies to restrict families and caregivers from seeing residents. There was widespread propaganda that seniors were responsible for spreading the virus when research showed that younger age groups held the highest burden of being infected [8]. This power imbalance between the state and seniors further puts the elderly population in a vulnerable position as they are forced to be isolated from society and restricted from the dignity of having equal access to health and well-being services [12].
Conclusion
Applying the 3-i framework to understand the policymaking process related to LTC homes showcases that the problem is multifaceted and goes beyond the healthcare system as it affects the daily living of seniors and their loved ones. LTC is excluded from the Canada Health Act (1984), meaning it is not covered by public health insurance. This leaves jurisdictions to allocate funds themselves. In Ontario, the Ministry of Long-Term Care regulates LTC homes through Health Integration Networks. Key actors in this policy area include government officials, LTC homeowners, families, caregivers, and healthcare providers. Each of these actors aims to influence LTC policy with the interests and values they hold. Moreover, some argue that the provincial government should mandate LTC as medically necessary while others emphasize individual responsibility. The burden of care often falls on seniors and their families as neoliberal ideologies continue to dominate Canada. This policy area is sensitive and subject to controversy as seniors are vulnerable members of society who are neglected in the care and support, they deserve.
Arooba Bari (she/her) is a Master of Public Health candidate at the Dalla Lana School of Public Health, University of Toronto. She is interested in health equity, social determinants of health, and policy implementation and evaluation. As a public health professional, she acknowledges the specific transgressions that the professional community has historically (and unfortunately continues) made against Indigenous people. Arooba strives to do better in her research and vows to work collaboratively with Indigenous communities in research that involves their community, and where possible, to prominently include this historically ignored population in her research pursuits.
References
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Canadian Institute for Health Information. (2024). Long-Term Care Homes in Canada: How many and who owns them?. CIHI. https://www.cihi.ca/en/long-term-care-homes-in-canada-how-many-and-who-owns-them
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Chu, C. H., Yee, A. V., & Stamatopoulos, V. (2023). “We’ve All Lost So Much”: The Long-Term Care Home Experiences of Essential Family Caregivers During COVID-19. Canadian Journal on Aging, 42(2), 284-296. https://doi.org/10.1017/S0714980822000496
Molinari, N., & Pratt, G. (2023). Seniors’ Long‐Term Care in Canada: A Continuum of Soft to Brutal Privatisation. Antipode, 55(4), 1089–1109. https://doi.org/10.1111/anti.12711
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