[Recent health services reform in Quebec Province, Canada: on the frontier of preserving a public system].

:This paper analyzes recent changes in the Canadian health system through a case study of Quebec. As the last Province to adopt federal principles of universal coverage, comprehensiveness, and public management, its reform, conducted in 1971, met these objectives by means of key innovations. In the 1980s and early 90s, a process of health services evaluation in this Province and in Canada as a whole launched a period of extensive changes. The relevant measures are described herein: decentralization and regional management, "clinical shift", selective reduction in the supply of services, and new mechanisms for resource allocation and social control. There is a tendency towards an environment of public competition, but the approach that was adopted for regulation does not correspond to the main models from central countries. Within a scenario of budget constraints, technocratically-defined measures allowed for the settlement of benefits, preserving the system's main guidelines. This evidence is one of the main contributions of comparative analysis to health system reform in peripheral countries. The study identifies the relationships between these measures and a worldwide trend towards cost control and macroeconomic adjustment policies, discussing the relevant implications for health services.

Conill EM 《Cadernos de Saude Publica》

Reliable in their failure: an analysis of healthcare reform policies in public systems.

In this paper, we analyze recommendations of past governmental commissions and their implementation in Quebec as a case to discuss the obstacles that litter the road to healthcare system reform. Our analysis shows that the obstacles to tackling the healthcare system's main problems may have less to do with programmatic (what to do) than with political and governance (how to do it) questions. We then draw on neo-institutional theory to discuss the causes and effects of this situation.

Contandriopoulos D ，Brousselle A 《-》

Avoiding fundamental reform: current cost containment strategies in Canada.

Provincial governments in Canada are trying very hard to contain and possibly reduce health care expenditure. The wide ranging effort and frequent announcements of yet another cost cutting measure, including deinsurance, stand in marked contrast to the complacency of earlier periods. This activist and serious effort to reform the system is certainly welcome, yet the reforms are not adequate and ignore some fundamental and structural problems of Canada's health care system. Health care reform must do one or more of three things, i.e., improve efficiency, effectiveness, and/or equity of the system. Many cost-cutting measures in Canada achieve none of these objectives and merely postpone costs to a later time or shift the burden on to the sick. Fundamental health reforms include the incentive systems influencing physician behavior and choices; efficiency gains via manpower substitution; more effective control over the supply and distribution of medical manpower; and changes in the organization and design of health care delivery systems. But these fundamental reforms are not being pursued in Canada even though this is an opportune time for such reforms. Also discussed is the potential for and problems associated with managed and/or public sector competition. This article is essentially a critical review of current cost containment efforts in Canada.

Manga P 《-》

[The right to health care services under Quebec law].

The main goal of the Canada Health Act is to guarantee that Canadian residents have reasonable access to a comprehensive and universal health care plan. However, reduced federal funding for health care and increases in health care costs due to technical and scientific developments have created unprecedented financial pressures on provincial health care systems. The right to health care, once perceived as one of the pillars of Canadian society, may be imperiled. This article will provide a detailed analysis of the nature and scope of the right to health care from mainly a legal, but also from a political, perspective. Based on the premises that the Canada Health Act is basically a financial agreement between the Federal and provincial governments and that it does not enshrine a substantive right on which individuals may claim services, the author explores the nature and scope of this right under Québec legislation. Indeed, the Québec Health and Social Services Act has, since the 1960s, included various provisions that establish a right of access to health care services. This right, however, is fraught with regulatory, organizational and financial limits. The first part of this paper examines relevant regulation from an historical perspective, highlighting the relationships between federal and Québec provincial legislation. In the second part, the author explores exhaustively the principal provisions relevant to the right to health care. This entails the analysis of administrative regulations as well as of the responsibilities of the various provincial, regional, institutional and professional authorities involved. Ultimately, as this study will demonstrate, the availability of health care services depends more on a vague process than on a legal right to health care. This conclusion is further confirmed by the analysis of the adjudication process of patient complaints provided under the Québec Health and Social Services Act and by the limited case law on the right of access to services. Even though judges are generally favorable to patients claims, court interventions remain ad hoc and a posteriori. But if the right of access to health care seems limited, its scope is nonetheless important. The right to health care acts as an obstacle to the current dismantling of health care services and to government withdrawal from this field. It also places limits on abusive, arbitrary and discriminatory decision-making and obliges public authorities to take into closer consideration patients' rights in formulating its health care policy and budgets. This protective role of the right to health care is currently illustrated by the politicians' insistence that the ongoing health care reform is not affecting the quality or quantity of available services.

Sprumont D 《-》

The changing nature of contracts in German health care.

The flexibility inherent in the German health care system is fairly limited. The contracting environment itself is characterized by bilateral cartels negotiating the terms covering their respective members. Looking at some recently implemented reforms, namely structural contracts and experimental settings, the paper assesses the potential for sickness funds to take on a more active role. The paper also evaluates the implications for the contracting relationships between the statutory sickness funds and provider associations. Furthermore, the potential effect of selective contracting on the health care system is studied. A look at the reforms recently enacted in other countries illustrates the difficulties contractual reform has to cope with in an environment characterized by strong informational asymmetries. It is postulated that both private and public choices are needed for a successful reform effort.

Riemer-Hommel P 《SOCIAL SCIENCE & MEDICINE》