Last January, the Commissioner for Health and Welfare (CSBE) published the fourth and final volume of his report on the performance of government home support (SAD) programs. We share certain findings contained in this report, including that of an insufficiency of the services offered and that of the need to make a major shift towards SAD. At a time when the National Meeting on Home Support is being held this week, in which the Commissioner is participating, it seems important to us to raise concerns about two problematic directions of the report: the openness to increased privatization of assistance at home and the recommendation of pricing for these services for users.
While professional home services (nursing care, psychosocial services, etc.) remain largely provided by public sector staff, home help services (domestic help and personal assistance) have undergone a process of transformation since 2003. accelerated privatization in Quebec. According to the most recent data we have (March 2022), only 14% of hours of publicly funded long-term home help services (CISSS and CIUSSS) are now provided by the staff of these establishments. The rest is outsourced to various types of private providers employing precarious staff, mostly women and, in large cities, migrants (employment agencies, private residences for the elderly, Service employment vouchers, social economy companies) .
The CSBE report recognizes some of the problems resulting from this privatization, including the multiplicity and instability of users’ stakeholders and the lack of coordination and coherence of services. Despite these findings, the report in no way calls into question the place of the private sector in home help. On the contrary, he recommends its strengthening.
This lack of critical examination of the effects of privatization leaves in the blind spot of the CSBE report issues that are nevertheless crucial for the future of SAD in Quebec.
Working conditions and quality of services
Here and elsewhere, scientific studies show that, in SAD as in other types of services based on the provision of care, working conditions have effects on the quality of services provided (better conditions are accompanied by better quality) and that the privatization of services deteriorates working conditions. However, the CSBE report, which had the mandate to evaluate the “performance” of the SAD, does not contain any evaluation of the working conditions and the quality of services offered by the numerous private home help providers nor any comparison of their “performance” on these two levels with public establishments.
Furthermore, the CSBE report deplores that there was “no public debate regarding the coverage of services [à domicile] which are offered free of charge to all people losing their autonomy”. Yet he does not propose that such a debate take place.
Based on consultations with a forum made up of 24 citizens and specialists as well as a non-probabilistic online survey, the conclusions of which obviously cannot be generalized to the entire population of Quebec, the report recommends rather, in the short term, “that the government imposes a contribution from users of home help financed by public services to people according to their means”.
Such a recommendation can only be defended if we see home help services as being “apart” from other socio-health services, a narrow conception of home help to say the least.
In fact, SAD, including home help, is an integral part of the continuum of social and health services. This is also the reason why its responsibility was entrusted to the CLSCs when the first SAD policy was adopted in 1979. This is also the reason why the 2003 policy provided that the health services home help are offered free of charge to users whose needs are certified by a professional assessment.
In Quebec, the principle of free social health services has been defended for years as a condition for respecting the rights to health and equality of all, in particular by union organizations and organizations defending the rights of people in situations of disadvantage. disabilities, seniors, women and migrants. The population is also very attached to this principle of free access, as shown by its opposition, in 2010, to the “moderatory ticket” project of the liberal government of the time as well as to the health tax, finally abolished in 2016.
While a major shift towards SAD is unavoidable and urgent in Quebec, it is crucial that this does not come at the cost of a deterioration of working conditions and to the detriment of accessibility and quality of services. .