The primary goal of the reform of the health and social services sector undertaken by Minister Christian Dubé is to increase the productivity of current services by proposing a radical change in the governance of the system by means of a new public company which will will call the Santé Québec agency. The agency will assume the management role that the Department of Health and Human Services has carried out since the hospital insurance and health insurance programs were established more than fifty years ago.
The ministry’s role will henceforth be limited to system planning. Management of the new system will be more centralized since it will be under the direct responsibility of a president and CEO supported by a board of directors. And it will also be more decentralized by giving back to service establishments the responsibility for operational decisions that they previously had.
It is obvious that the healthcare system is going through significant difficulties. But the overall reform project was not based on an exhaustive assessment of the current functioning of the healthcare system. The idea of creating the Santé Québec agency is inspired by the structured management model of a large company which would have three levels of management: a “head office” which would supervise the operation of the second level, made up of 21 subsidiaries corresponding to the centers integrated services. These subsidiaries would then supervise a third level, made up of 1540 establishments.
The agency will therefore be a huge undertaking whose components already exist under the responsibility of the Ministry of Health and Social Services. Why could it be better able to manage this sensitive sector by being outside the framework of the government structure? Let’s take a step back to try to answer this question.
Current health systems developed during the 20th centurye century. Care services have historically been provided by private for-profit or non-profit organizations, as was the case in Quebec, where religious communities played an important role. This development has gradually challenged governments, because they are ultimately best placed to manage and equitably finance the sharing of the risk of disease for the entire population.
Funding has been a crucial point in the development of current systems. They can be financed in two ways. The first is the subsidy from government revenues. Like the United Kingdom, this is the method of financing that was chosen by governments in Canada when it was decided, in the 1960s, to have public health care systems. The second model is based on the principle of compulsory insurance, which is the most widespread way of doing things among developed countries.
The two financing models, however, gave rise to two very different ways of organizing care. Funding through government revenues has led to the establishment of centralizing and rigid systems that are based almost solely on public health care organizations. The worst example is that of England.
On the other hand, the model based on insurance has led to a much more flexible organization of care, because governments have left an important role to private organizations. These public systems are much more efficient, for example in France and Germany, compared to the systems in Canada.
It would be impossible to rebuild our health system by asking the population to pay insurance premiums or any other form of special financing. Rather, we must improve the existing system by keeping what currently seems most functional and integrating certain compatible elements proposed in Minister Dubé’s reform. The following proposition is based on this approach.
First, the basis of the regional structure of integrated management centers should be maintained. They would be independent and they would continue to have the responsibility of coordinating the operation of the establishments in their territory. But they could also become the sole employers of the regional system, in order to better meet the labor needs of establishments in their territory, as the reform already proposes for all of Quebec.
Second, healthcare establishments should once again become responsible for their own operational management. This aspect is also provided for in Minister Dubé’s reform.
Third, professional councils at the institutional level should be integrated so that they can exercise their role effectively and to the satisfaction of professional organizations.
Fourth, the ministry must maintain its responsibility not only for the planning and organization of the health system, but also for the medium-term strategy and annual monitoring of its operation.
By building on what already exists and improving the operational functioning of the health system under the supervision of the ministry, the authorities will have a greater chance of achieving concrete and rapid results. Minister Dubé’s radical change is a worrying reflection of a loss of confidence in the government apparatus and public administration. It is absolutely necessary that ministries remain the fundamental institutional basis for the functioning of our public sector.