The Health and Social Services System

General Characteristics

Under review

In many ways, the Québec health and social services system is similar to those in other Canadian provinces. Everywhere in  Canada, access to medical services and hospital services is subject to the same rules, and the general organization of services is similar. In other important aspects, however, the Québec system has its own peculiarities. These similarities and differences stem from the very origins of the system and from its recent developments.

Canadian Features

Health is an area of provincial jurisdiction. However, since the middle of the 20th century, the federal government has used its spending power to gradually establish a truly Canadian health insurance  system and to impose its vision on the system’s development. From this perspective we can understand this government’s great exercises in planning, notably the Hall Commission in the early 1960s, the National Forum on Health in the 1990s, and the Romanow Commission in the early years of this century.

The Government of Canada has also used legislation to gradually imprint its own vision. The Hospital Insurance and Diagnostic Services Act (1957) was a first step. It came hand-in-hand with equal cost-sharing between the central government and the provincial governments. This was also the case with the Medical Care Act (1966), aimed at inciting the provinces to promulgate a similar law and thus cover medical costs. This measure represented a decisive step in establishing a universal health insurance plan. The legislation set four conditions for the provinces: the services must be universal (at least 95% of the population must be covered); comprehensive; portable (access provinces); and publicly administered.

These principles would be reiterated, adapted and strengthened in the Canada Health Act (1984). We know that it was adopted to counter the over-billing of medical services in certain provinces, particularly in Ontario and Alberta. Above all, it laid the groundwork for the “Canadian health insurance plan”.

Today, everywhere in the country, the provincial plans must respect the following five principles:
⎯ accessibility;
⎯ universality;
⎯ comprehensiveness;
⎯ portability;
⎯ public administration.

These principles apply to medical services and hospital services. From the Canadian perspective, they do not apply to other service sectors. Furthermore, while the federal government’s share of the funding has steadily decreased over the years—in 2004, it cover no more than 16% of the costs, compared to 50% in the mid-1970s—the principles stipulated in the Canada Health Act  have retained all of their political legitimacy given that they have the support of a very large segment of the population. Discussions on these principles have nonetheless been reopened by a decision of the Supreme Court issued in June 2005 in the Chaoulli-Zéliotis case, which ruled that it should be possible to resort to private insurance to obtain medically required care, when waiting times in the public system are “unreasonable”.

Québec Particularities

Since its creation, the public system in Québec has always brought health services and social services together under one administration. Québec is the only province to maintain this kind of integration. This has the advantage of better responding to the needs of populations that require a lot of  services, particularly the elderly who have lost their independence, and the handicapped.

Québec is also the only province to have established a general drug insurance plan. The other provinces have various selective programs serving specific populations, and these give rise to access problems. Before this plan was instituted in 1997, 20% of the Québec population had no public or private drug insurance.

Québec is also the province that has paved the way for decentralization in Canada. Since then other provinces have followed suit, taking it even further. Finally, in response to the Supreme Court ruling, Québec is the first province to legislate certain organizational changes likely to increase access to care, as well as the possibility of using private resources in specific cases  where the care required is not accessible within medically reasonable waiting times.

Indeed, in December 2006, the Québec government amended its Act respecting health services and social services and other legislative provisions to establish a central management mechanism in hospital centres giving access to surgical procedures and allowing the use of private facilities and private insurance if access to three procedures (knee and hip arthroplasty and cataract surgery) is not available within a reasonable waiting time. Bill 33 established the legal framework whereby certain medical services usually provided in an institution may be provided outside an institution, that is, in specialized medical centres (CMS), some of which may be completely private (nonparticipating physicians), or in associated  medical clinics (CMA), where physicians participating in the public system would  have entered into agreements with these establishments. All centres providing services determined by regulation would meet three requirements:

  1. obtain an operating permit from the government;
  2. name a medical director responsible for ensuring the quality of medical services;
  3. within three years of issuance of  the permit, be accredited by an organization recognized for this purpose.