The Health and Social Services System

The Québec Way

Under review

The health and social services system is a pillar of social policy in Québec. To the individual it offers a guarantee of security in case of health problems. To the community at large it represents an instrument of social justice and progress.

The Québec health and social services system was established in 1970. This was a pivotal moment, marking a culmination, on the one hand, and a point of departure, on the other.

A Culmination

The creation of the public health and social services system was the culmination of a long developmental process. It seems unnecessary to recall every milestone in the history of medical services and, in a more global sense, of health and social services in Québec. Suffice it to mention the salient facts:

1886 The Public Health Act was enacted; its mandate was to check the spread of infectious diseases and to improve sanitary conditions;
1921 The Québec Public Charities Act was adopted. The government would henceforth intervene in the area of helping the needy, an area heretofore restricted to the Church and to groups doing good works;  
 As of 1926 Clinics were set up, making for immense progress in matters of public health. These would also serve as models for other societies; 
1936 The first Ministry of Health was created to settle the thorny question of hospital deficits and to improve the overall administration of hospitals. 

In Canada, as in all industrialized countries, the end of World War II launched a period of progress in the area of social policy. This was the beginning of the thirty-year boom period, from 1945 to 1975, three decades marked by economic prosperity unprecedented in our history. As for Québec, it would have to wait until the early 1960s and the end of the Duplessis era to experience that same effervescence. Indeed, Québec would be transformed by teeming cauldron of social ferment. This was the period of the Quiet Revolution.

In the decade preceding it, the federal government had laid the groundwork for social measures. It had implemented old-age security (1951), unemployment insurance (1956) and a measure that would have a decisive effect on the development of health services—hospital insurance (1957). The federal government drew its inspiration from the Marsh Commission (1943), considered to be Canada’s social charter, and from the policies of Great Britain and the Beveridge Report (1942), which lead to the implementation of the British health care system, the National Health Service (1948).

Saskatchewan was the first province to establish government-funded systems, namely a hospital insurance plan in 1948, and a universal health insurance plan in 1962. The Cooperative Commonwealth Federation (CCF), precursor to the New Democratic Party (NDP), may therefore be considered as the “father” of health insurance in Canada.

In Québec, a series of measures were enacted, in particular the Hospital Insurance Act (1960) providing free hospital services to the user, the Act respecting the Québec Pension Plan (1965) and the Social Aid Act, all of which represented the Québec government’s first incursion into the field of professional practice. In matters of health, social services and social development, however, the lack of a global perspective was still a matter of deep concern. Conclusions  would emerge from two important task forces—the Boucher Committee (1963) studying public assistance, and the Castonguay-Nepveu Commission (1966-1972) mandated to inquire into health and social services. The first recommended that  the public sector take over assistance activities from the church and other charitable works groups. It insisted that Québec adopt an integrated economic and social policy, and it defined its broad parameters. As for the Commission, it submitted to the government a global and generous vision of social security based on three pillars: health, social services and income security. It also proposed the implementation of innovative services that would take into account these concerns.

A Point of Departure

In the early 1970s, the Québec government gave itself a new legislative framework to support the implementation of the public health and social services system. This framework included the following key pieces of legislation: the Act respecting the Ministère des Affaires sociales (1970), the Health Insurance Act (1970), and the Act respecting health services and social services (1971).

The new ministry of social affairs was responsible for implementing the overall policies of the government in matters of health, social services and income security, and for defining the rules for the administration and operation of the institutions. The Health Insurance Act instituted free medical services for the user. The Act respecting health services and social services broadened the scope of the Health Insurance Act and provided for universal access to a complete range of health services and social services. It also specified the mode of organization of this new public system, namely the mission of institutions, the role and responsibilities of the institutions’ committees, the role and responsibilities of the new regional bodies (Regional Boards of Health and Social Services), the powers of the Minister, etc.

The Québec of the 1970s was one great beehive of activity, a going concern. But quickly, the new organization would run into obstacles that would affect its development in the subsequent thirty years.

  • The costs of services continued to increase rather than decrease as had been predicted after the required period of investment given that the population should be healthier. Thus, the problem of hospital deficits, in particular, remained unresolved. 
  • The new institution, the CLSC, which was to be the cornerstone of primary care services, did not fulfill its promise for a variety of reasons: hesitation on the government’s part, lack of resources,  unfavorable climate in certain CLSCs, resistance on the part of physicians to practice there, etc. In this context, medical clinics and hospital emergency rooms became the real first line.
  • The coordination of efforts had its deficiencies; the dividing lines between institutions and between professionals were impediments to the effectiveness and efficiency of services.
  • The centralized decision-making progress made for great rigidity.

These difficulties would become more pronounced over the years and, coupled with the economic crisis in the early 1980s, would lead to an impasse. The government then created an inquiry commission chaired by Dr. Jean Rochon; its mandate was to find solutions to the problems of funding and operating the system. Fifteen years later, another study commission chaired by Michel Clair would be given the very same mandate. Yet during this period, we would witness profound changes that would clearly improve the system’s general performance. But these changes did not appear to satisfactorily resolve the basic problems that had remained since 1970: the weaknesses in primary care; the ever growing needs in matters of coordination, and the funding problems. Reforms are still under way to tackle these very problems. Two other task forces were set up in recent years to re-examine the problem of funding. One, chaired by Mr. Jacques Ménard, tabled its report in July 2005; the other, chaired by Mr. Claude Castonguay, the very father of health-insurance in Québec, published its report in February 2008. These two reports identify an increase in health expenditures in excess of government revenues, inevitably leading to a financial impasse. To offset the impasse, they propose using additional revenues, either in the form of a specific tax or private funding sources (user’s contribution, insurances, etc.). The mixed aspect of medical practice is at the heart of the debate. They also note that there is more room for improvement in the efficiency and effectiveness of the public system, whose adaptability and flexibility are still weighed down by a cumbersome bureaucracy that seems resistant to streamlining.