The voluminous Bill 15 (PL15), tabled on March 29 by Minister Christian Dubé, promises to “make the health and social services system more efficient”. The network is currently facing major problems requiring profound transformations. At their source are the tendencies towards centralization, the elimination of democratic bodies and the privatization of services imposed by the reforms of recent decades. However, rather than reversing these trends, PL15 will have the effect of deepening them.
In research published Thursday, IRIS draws on best practices to offer a decentralized and democratic network management model. Our research has shown that chronic underfunding and poor distribution of public funds invested in the network are among the causes of the multiple and complex difficulties facing the health system.
In terms of the organization and management of services, international literature on public administration shows that the most effective public services are those which are managed in a decentralized manner and with citizen participation in places of decision-making power.
In this regard, we can highlight three main failures within the Quebec system, all of which are interrelated: 1) excessive centralization of the network’s organizational structure, which makes it inefficient by distancing managers and decision-making power from reality field daily; 2) an absence of democratic spaces for staff to participate in decision-making and for people to express their needs and have control over the services they receive; 3) an increasing delegation of the provision of services to the private for-profit sector, and the application to the public sector of authoritarian modes of management directly inspired by the methods specific to private enterprise, which degrades the quality of services and the conditions staff work.
Centralization
However, the creation of the Health Quebec agency is a continuation of previous centralizing reforms, including that of 2015, yet unanimously denounced for its deleterious effects observed during the pandemic. In a recently published report, Deputy Minister Dominique Savoie acknowledges this: since the early 2000s, the evolution of Canadian health systems has led to their centralization, including in Quebec, and the creation of a new central authority. part of this trend.
But the tendency is not only towards centralization. It is also the elimination of the many instances of citizen participation which have nevertheless been the originality of the public system since its creation in 1971. The PL15, which provides that all positions of power within the new structure will be filled by vertical appointment , is the result of this evolution.
As for the users’ committees, the only bodies whose members are elected, PL15 grants them no power, and their activities will be supervised and supervised by a national users’ committee whose members will be entirely appointed by Santé Québec and whose director will be “under the direct authority” of its CEO
With respect to the privatization of services and management methods imported from private enterprise, Minister Dubé’s intentions are very clear, as shown by his intention to resort to top guns from the private sector. The PL15 commits to an intensification of hierarchical controls and quantitative and productivist reporting requirements that say nothing about the quality of services. On the contrary, this managerial approach partly explains the deterioration in the conditions of practice of professionals and their exodus from the public network.
If the words are significant, it is interesting to note that the term “private” appears 202 times in the PL15, against 145 for the term “public”. In the Act respecting health services and social services, which founded the public health system and which Bill 15 will replace, these numbers are 155 and 222 respectively.
Since its analysis of the second Castonguay report in 2008, IRIS has shown that centralization, the denial of democracy and recourse to the private sector, which were at the heart of the reforms of the last decades, are the source of the problem, not the solution. Our research published Thursday shows that other models exist and have been proven. It is therefore possible to draw inspiration from them rather than repeat the mistakes of the past.