managing health care costs; traditional versus new organizational models; current social conditions versus societal goals; and maintaining the status quo versus shifting paradigms (Casebeer and Hannah, 1995). Regionalization of the health care system in the province of Alberta constitutes a significant change in the arrangements for managing and providing health services. The change is largely an attempt to control increased health care spending, which grew from 20 to 32 percent of the provincial government's budget between 1980–1981 and 1993–1994, and to alter the orientation of health care provision (managing the system regionally and shifting to a population-based, community-based, health-promoting focus for care).

A study of change in health care and health policy identifies processes of change used by managers, as well as expected and actual health outcomes (Casebeer, 1996). Managers have suggested that successful change depends on the development of structures, processes, and outcomes that encourage the system to change in positive and sustainable ways.

With regard to structures, these managers are attempting to work with

• new and broader governance roles;
• leaner, flatter, more horizontal management of the system;
• new working arrangements for health care providers and managers; and
• new participatory roles for communities.

In relation to process issues, managers emphasized several critical aspects of change:

• the importance of sustaining political will;
• the pace of change;
• the capacity for shifting resources;
• the need for a renewed commitment to positive change;
• improved communication capabilities;
• better information;
• effective planning; and
• time for learning and adjusting.

Managers articulated a range of hopes and concerns in relation to short-term and long-term outcomes. For example, they expect that new management structures and savings would be short-term outcomes, new ways of developing services for better information would be medium-term outcomes, and improved services and health status would be long-term outcomes.

Gaining a better understanding of health care change such as that taking place in Alberta will require additional longitudinal and comparative experience as well as targeted research.