Rebalancing health systems toward community-based care: The role of subsectoral politics

[Display omitted] •Policy efforts attempt to rebalance health systems from institutional towards community-based approaches.•Despite these efforts it remains a challenge to shift from institutional approaches.•The health sector has disparate subsectors that can affect sectoral change.•The community subsector lacks legacies and actor networks needed to become critical.•It is difficult to challenge the dominance of acute care subsectors. There has been increased policy discourse urging a “rebalancing” of health systems from institutionally-based to community-based approaches. This paper offers an analysis of the subsectoral dynamics that condition opportunities to strengthen community-based care relative to acute care. We report on the results of a policy study in Ontario, Canada that explored factors impacting on the capacity to expand community-based care. In so doing, we highlight the challenges associated with the community subsector’s ability to develop ‘critical’ status and challenge the dominance of the acute subsector. We conclude that attempts to rebalance health systems toward community-based care should begin by understanding that health care is not a monolithic policy sector, but rather a collection of proximate policy sub-sectors, inclusive of community care, acute care, and institutional care, each with their own internal characteristics and dynamics that impact sectoral directions.