Sans préjudice...pour la santé des femmes. Winter 2005, Number 34

Since the Charest government's arrival in power, private-public partnerships (PPPs) have been a regular item in the Quebec news. Originating in the British neoliberal era of Margaret Thatcher, the PPP model is not a new phenomenon in Quebec. Various "small-scale partnerships" have operated for a long time now; indeed, many private health institutions and services are financed by the State, among them, long-term care residences, medical clinics and radiology clinics. Nearly 40% of our health expenditures in Quebec are incurred in the private sector.

In the 1990s, public health care budgets shrank. The gradual amputation of public financing for health care is the consequence of trade agreements on government contracting (1) that started being negotiated in the 1980s. According to Jennie Skeene, president of the Fédération des Infirmières et infirmiers du Québec (FIIQ), it was a "concerted process to accelerate the privatization and commercialization of the public sector" (Brouillard 8). World Bank(2) strategies to privatize public services were implemented in Quebec with the health reform, and several bills were adopted under a gag order in December 2003 and December 2004. These laws create structures to comply with the requirements of trade agreements (Bill 25); throw open the doors to sub-contracting (Bill 31); and, by allowing the disaffiliation of a portion of the workforce and reducing labour unions' effectiveness, offer lucrative investment opportunities for private investors (Bill 30). Finally, the new Act respecting the Agence des partenariats public-privé du Québec (Bill 61) creates an agency to promote and oversee private-public partnerships.

Now that we have this agency in Quebec, we should at least examine what is not being said about the PPPs. By reviewing the experience of health sector PPPs in other countries, we will study the possible impact of this model on health services. We will consider the findings of our survey on women's anxiety and support needs after an abnormal breast cancer screening mammogram in terms of some of the effects of privatization on the quality of services offered to participants in the Quebec Breast Cancer Screening Program.

The stakes underlying the privatization of health services
First, the privatization of public services, including health services, clearly marks a return to the early 1900s, an era when the private sector exercised a monopoly in several domains: electrical power, public transportation and health services. With the adoption of charters of rights, social legislation and universal rights protection instruments, immense progress towards a more just and more egalitarian society was achieved. This shift backward is rooted in the dominance of a neoliberal agenda that masks its antidemocratic and ideology-driven character.

According to neoliberal ideology, which is supported to a great extent by the media, public health services cost too much (the State can no longer "afford to pay") and these services are badly managed; private services are more "efficient": they are of better quality, cheaper and faster. There are no objective grounds to support these affirmations. On the contrary, numerous studies, particularly of the U.S. and British health systems, show that privatization and private-public partnerships lead to the commodification of care, conflict of interest, lower service quality, reduced accessibility for disadvantaged persons, and, to top it off, increased costs for the State (see Kalant, 2001, for numerous references).

Furthermore, other studies show that the transfer of some health services to the private sector has increased waiting lists in the public sector. According to the U.S. studies, physician clinic owners provide "excessive" services to their patients, for example, too many X-rays (FIIQ 2004b 16; Kalant). After 10 years of implementing the PPP health services model in Great Britain, the British Medical Association found that, "data continue to show that private initiatives in hospitals are exceedingly expensive and do not satisfactorily meet our expectations with respect to service accessibility, resource optimization, transfer of risk and service cuts," (FIIQ 2004b: 17). In fact, privatization means making the public pay while the private sector reaps the profits!

The QBCSP
Established by the Bouchard government in 1998 in a context of budgetary crisis and zero deficit goals, from out outset the Quebec Breast Cancer Screening Program (QBCSP), leaned strongly toward privatized services. When the Program was instituted in Montreal, initial screening mammography was supposed to be done in a private radiology clinic (3) , and additional examinations to determine the nature of an anomaly were to be conducted in a hospital. The Program in effect constitutes a health PPP that was never named as such. Yet, the QBCSP clearly corresponds with the definition of a PPP under Bill 61 (section 6): "A public-private partnership contract is a long-term contract under which a public body allows a private-sector enterprise to participate, with or without a financial contribution, in designing, constructing and operating a public work. The purpose of the contract can be the delivery of a public service. "

Although initially, participants were supposed to have their additional examinations in a hospital, the majority of participants, or three out of five women, had their additional examinations performed in a private radiology clinic. Fees were charged to participants for most of these examinations. Furthermore, a third of the participants were not informed by designated screening centre (DSC) staff that these examinations were free of charge when performed in a hospital (RQASF 2004: 52).

According to survey findings, the profile of participants who used private services is not the same as that of women who used public services. Women who had their additional examinations in a hospital had a lower family income and level of formal schooling; they were more likely to be on sick or disability leave and a larger proportion of them received social assistance or employment insurance benefits. This is contrary to the Program's stated desire to ensure "equitable and accessible service to all sub-groups of the population" (Programme québécois de dépistage du cancer du sein 8).

The survey's conclusions reveal numerous other shortcomings of the QBCSP, particularly regarding service quality in private radiology clinics (DSCs). Women receive much less encouragement to talk about their fears in these clinics than in the hospitals (RQASF 2004: 39); they are less satisfied with the emotional support they receive (RQASF 2004: 40); they are given less information (RQASF 2004: 42); and are less satisfied with the information they do receive (RQASF 2004: 43). Analysis revealed that participants' anxiety was not lower when they were informed of an abnormal breast cancer screening in person by DSC staff than when they were informed in a letter from the QBCSP (RQASF 2004: 51).

Regarding waiting periods, the survey findings challenge commonly held assumptions. While the waiting period before additional examinations begin was generally shorter with the private clinics, the actual process of completing the additional examinations was not faster if they were conducted in a private clinic. As for biopsies, more women got their results faster when they were performed in a hospital (RQASF 2004: 52).

Were the promises of service quality, shorter waiting periods and greater accessibility honoured by resorting to the private sector? The results of our survey seem to indicate the contrary.

RQASF
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(1) Opening public services (health, education, housing, water, transportation, etc.) to competition through contracts signed with the private sector (PPP). Public administrations were then obliged to issue tender calls to supply themselves with goods and services.

(2) These strategies are: planned resource deficit; deregulation; rate setting; decentralization/regionalization; privatization and communitization.

(3) DCS: designated screening centre named by the Ministère de la santé et des services sociaux.

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References

Brouillard, C. "Une entrevue avec Jennie Skene sur les réformes dans le réseau de la santé : des restructurations à saveur marchande". À bâbord! (Jan.-Feb., 2004) p. 8-9.

Fédération des infirmières et infirmiers du Québec (FIIQ). Des marchés publics dans la santé. Montréal/Québec: FIIQ, 2004a.

Fédération des infirmières et infirmiers du Québec (FIIQ). L'Agence des partenariats public- privé du Québec ou la construction d'un État marchand. Brief. Montréal/Québec: FIIQ, 2004b.

Kalant, N. La Commission royale sur l'avenir des soins de santé au Canada (Romanow). Brief for the Coalition des médecins pour la justice sociale. 2001.

Programme québécois de dépistage du cancer du sein (PQDCS). Cadre de référence. Québec City: Direction des communications du Ministère de la Santé et des Services Sociaux, 1996.

Réseau québécois d'action pour la santé des femmes (RQASF). Dépistage du cancer du sein : ce que vivent les femmes en attente de diagnostic. Montréal: RQASF, 2004.