The Quebec government wants to centralize the health-care system even more with Bill 130, giving the health minister more power over administrators and over the management and operation of hospitals. The government would be better off following the example of Sweden, which has successfully moved in the opposite direction, in addition to benefiting from the contribution of the private sector.
One notable difference with Quebec is that in Sweden, the government has a very limited degree of bureaucratic control over the health-care sector. Essentially, Stockholm is responsible only for establishing principles and guidelines, patient safety and setting the political agenda. This is a far cry from the health department determining the one menu to be served in every hospital, clinic and long-term care facility.
As for the funding and provision of services, they fall under the jurisdiction of Sweden's 21 county councils. It is up to each county council to arrange, administer, and oversee the way health care operates. Unlike in Quebec, different regions apply different strategies. Some offer hospitals financial incentives like linking reimbursement to the volume of services provided, while others still allocate hospital funding according to global budgets.
Either way, hospital administrators have substantial autonomy. They have full authority to adjust service provision based on demand and resources, including the power to hire or lay off doctors and other staff.
This does not preclude political action if a hospital underperforms or exceeds its given budget. Hospital management must also comply with labour market and environmental legislation, rules on the reporting of statistics, and so forth. But again, hospital administrators are entrusted with the authority to handle such tasks, without any specific hospital-related rules.
Time for a change
By tightening its grip on the management and administration of hospitals, the Quebec government is moving in the opposite direction. This is not a new trend, but that doesn't mean that a change would not be welcome.
Uniform approaches and the multiplication of decision-making levels prevent the experiments required to improve the way we do things. To be blunt, if we don't want to read the same news about the same failings of our health-care system in 20 years, we need to radically rethink our methods.
Instead of subjecting tens of thousands of health care workers to a centralized authority, they should be given both more freedom and more responsibility. This obviously starts with hospital administrators, who need to have wide discretion combined with an obligation of accountability. The same approach should also be applied to those who take care of patients.
The most important reform
The implementation of accessible, transparent performance indicators would also be beneficial, as would activity-based funding, which turns the patient into a source of revenue instead of an expense. But the most important, essential reform would be to allow the private sector to complement the public system as well as introduce some competition into the provision of care.
In Sweden, many private care providers now operate side by side with public providers, seamlessly integrated into a publicly funded system. Patients make copayments to cover a small fraction of the cost of medical fees and medication. Yet all facilities, private and public, are financed in the same way, with public funds: Patients access care with the Swedish equivalent of a Medicare card, not with a credit card.
Far from being a threat to universal access, integrating private provision of care into the system has helped make Sweden's egalitarian values sustainable: Access to frontline care is quicker than it is in Quebec, and the wait to consult a specialist or undergo surgery is shorter. And also, in Sweden, the proportion of patients who had to forego care because of cost considerations is lower than it is in Quebec.
The Swedish model, like many others, shows that there is no contradiction between private provision of care and equal access, and that competition on the contrary leads to improved services for patients. A key part of the success of this model can also be attributed to hospital-level autonomy, a lesson that our politicians, with their tendency to prefer centralization, could benefit from studying.
Germain Belzile est chercheur associé senior, département des actualités, à l'IEDM. Il signe ce texte à titre personnel.