Quebec’s public healthcare system is facing a precarious future, according to a recent report by the province’s Health and Welfare Commissioner. The report, released by Joanne Castonguay’s team, raises concerns about the long-term sustainability and efficiency of the system, particularly in the face of an aging population and tightening public finances.
The findings come as Quebec grapples with ongoing efforts to improve access to care. Former Health Minister Christian Dubé, in March 2023, introduced a sweeping bill – Bill 15 – aimed at increasing efficiency, which included the creation of a state-owned corporation to manage the healthcare network. However, the Commissioner’s report suggests that fundamental challenges remain.
The report highlights a concerning trend: Quebec’s healthcare spending, at 9.5% of its Gross Domestic Product (GDP) in 2022, is higher than the median among comparable countries. This elevated spending level, coupled with demographic shifts and rising costs, necessitates a re-evaluation of current practices to ensure the system’s viability, according to the Commissioner.
A key indicator of these challenges is Quebec’s performance on the public administration performance dashboard prepared annually by the Treasury Board. The Health Ministry ranks near the bottom, alongside Education, suggesting systemic issues within the sector.
The central question addressed in the “Grands Repères” report was whether Quebec’s health and social services system is viable and efficient. The conclusion is stark: “The viability of the public health and social services system is fragile and needs to be monitored.”
One critical area of concern is the shortage of healthcare professionals. In 2022, Quebec ranked 15th out of 18 comparable jurisdictions in terms of physicians per 1,000 inhabitants, 12th out of 18 for nurses, and 17th out of 18 for hospital beds per 1,000 inhabitants – a figure that has remained stable since 2015 and is among the lowest in the comparison group. This scarcity of resources is compounded by an aging population, increasing demand for services.
Castonguay acknowledges that simply increasing the number of healthcare professionals is not a realistic solution. “We could say, ‘Let’s get more human resources,’ but we know we won’t have them,” she stated. Instead, she argues for a fundamental shift in how the healthcare system operates, emphasizing changes in practices and organizational models to move care outside of hospitals.
The report underscores the need for difficult choices. “That means we will have to find funds elsewhere, and therefore either we will have more debt, or we will have to cut back on other government responsibilities, or we will have to become more efficient, and that’s where we need to work: becoming more efficient,” Castonguay explained.
Focus on Capitation
The report identifies capitation – a payment model where healthcare providers are paid a fixed amount per patient, regardless of the number of services provided – as a potentially positive development. This approach, according to Castonguay, shifts responsibility away from individual physicians and distributes it among multiple actors.
“Capitation is not progress, it’s essential […] Instead of having all the responsibility on the shoulders of the doctor, we are going to separate the responsibility between several actors,” she said. The Commissioner advocates for experimentation and evaluation as the system transitions to this model.
However, recent reports have raised concerns about potential limitations within the capitation system, suggesting that certain exclusions could undermine the anticipated benefits for patients.
Access to care is expected to remain a crucial issue in the coming years. Without improvements, the report warns, there is a risk of increased reliance on the private sector. “That’s when the loss of confidence in the system will occur, and that’s when people turn to the private sector. If we don’t react, it will get worse,” Castonguay cautioned.
Areas of Strength
Despite the challenges, the report also highlights areas where Quebec’s healthcare system excels. The province demonstrates efficiency in specialized health services, with outcomes exceeding the median among comparable OECD countries. Specifically, five-year survival rates for certain cancers and 30-day mortality rates following acute myocardial infarction (heart attack) indicate that healthcare spending is translating into tangible benefits for patients.
Castonguay emphasizes that the overall health of Quebecers is generally good, a positive outcome that is not solely attributable to the healthcare system itself. She notes that only about 20% of health is explained by the healthcare system, with lifestyle and other factors playing a significant role.
Improving Prevention
The report identifies prevention as a key area for improvement. While Quebec’s total healthcare spending per capita is comparable to other OECD countries, its efficiency in preventative care is significantly lower. The report uses an aggregated indicator that includes influenza vaccination rates among seniors and screening rates for colorectal and breast cancer – interventions crucial for reducing avoidable hospitalizations and improving treatment outcomes.
Castonguay argues for a shift in philosophy, from “treating people when they are sick” to a system that proactively addresses health before illness manifests.
With provincial elections on the horizon, the Health and Welfare Commissioner hopes the “Grands Repères” report will serve as a tool to inform public debate and encourage a broader discussion about the future of healthcare in Quebec.
