May 25, 2023 - No. 28

Quebec Government's Health Care Bill --
Radical Rupture with the Past

A Modern Quebec Can and Must Guarantee
the Right to Health Care

Action by health care workers outside Quebec National Assembly, December 13, 2022 demand action from governments affirming that it is them, not the workers who are failing those who are sick.

Massive Concentration of Decision-Making Power
and Union-Busting

– Pierre Chénier –

Previous Restructuring of Quebec's Health Care System

– Pierre Soublière –


Nefarious New Health Act Receives Royal Assent

– Enver Villamizar –

Ontario Health Coalition Referendum

Quebec Government's Health Care Bill -- Radical Rupture with the Past

A Modern Quebec Can and Must Guarantee the Right to Health Care

The principle of public health is based on the fact that the society has attained such a level that its future prosperity depends on expanding public services. The enormous development of the productive forces in Quebec and Canada and the technological revolution driving this in all spheres of life should be reflected in a corresponding growth in the capacity to meet the needs of the population, including micro-surgeries and the latest prostheses.

However, the opposite is true. The refusal to meet the needs in health care causes increasingly serious problems. Instead of taking on the social responsibility, governments are taken over by private interests and take anti-social decisions for private gain. This is the case with the "health reform" of the Legault government in Quebec. Bill 15, An Act to make the health and social services system more effective, tabled by Quebec Health Minister Christian Dubé on March 29, shows that the government is not capable of solving the problems of a modern Quebec. It also shows that the government will use any means to silence those who claim their rights and to dismiss all those who are the crucial factor in providing solutions -- the workers who provide the existing services and know first hand what is required.

The bill puts in place a structure that further centralizes decision-making, frees the government from accountability and debilitates health care workers' defence organizations. It also shows its obsession with "coordinating" what are called "user complaints." It proposes the creation of a "national user committee" and a "national complaints commissioner" with a responsibility to "harmonize the practices of user committees and make recommendations." It is to manage "Quebeckers' dissatisfaction with their health care system," which it finds "unacceptable." 

The government uses the expression "top guns" to describe its intention to seek out the best private sector administrators to carry out this reform. In this way, Minister Dubé tries to give the impression that this time privatization of the management of health care is going to work. This is a way of admitting that the last four decades of reforms, which have turned the people's health care into an opportunity to make profits at the expense of national standards, and especially at the expense of the people's needs, have not gone well and now require "top guns" -- a U.S. expression which refers to the top fighter pilots in the U.S. air force.

The criminal irresponsibility of the private management of centres for our seniors was exposed during the pandemic and amply documented by the Kamel Commission which submitted its report in May 2022. The construction of Montreal's major university hospitals was so rife with corruption and inordinate private enrichment that half a dozen "top guns" from SNC-Lavalin ended up behind bars.

Governments taken over by private interests are not guided by the aim of providing the right to health care with guarantees. They are guided by the neo-liberal mantra that to develop society, all the nation's resources must be put at the disposal of the same narrow private interests in command. Motivated by the pursuit of private profit, these private interests create projects that serve themselves and, as a secondary consideration, could have "societal benefits." In other words, the rights of the people are left to chance and made subject to limits, while the demands of the rich are given a guarantee and no limit is placed on them. This is achieved through deregulation, the abandonment of national standards, and an all-out assault on rights.

There is much confusion about what privatization of health care means. The government says that using private intervention does not mean that users will be required to pay or that there will be a two-tier system. This is then used to say that there is no problem and everyone should just be happy they have "access to free health care" whether publicly or privately managed and operated.

This is disinformation. First of all, it is not true that there is not a two-tier system. Anyone who has had to use the health care system in recent years knows that, despite the denials of successive ministers of health, the situations are many where people can have faster access to services in exchange for payments or paid subscriptions. Furthermore, as a researcher from the University of Sherbrooke explained in a recent article in Le Devoir, "federal transfers to Quebec have been reduced because of the tacit acceptance [by the Quebec government] of paid access to private diagnostic services (magnetic resonance imaging, for example), in the absence of sufficient coverage of these services within the public system." There is also an increasing number of "medically necessary" services that can now be obtained from non-physicians, outside the public system, at the patient's expense.

Second, the principles of universality and accessibility are being undermined by the handing over of the management of the health care system and decision-making power to private interests. This means that needs are met on the basis of what can be privately profitable for someone. Minister Dubé says the goal of this new bill is to make the system "more humane," but this reform, which continues the reforms of the past four decades, turns humans and their needs into things and opportunities for profit.

The claims that human beings are entitled to make on society are the real engine of development in any modern society. A modern Quebec begins with the recognition of the right to health care as a right that belongs to everyone by virtue of their being human and that governments have a duty to guarantee. Guaranteeing this right means that people have recourse if the government does not fulfill its obligation. So long as the right to health care remains a policy objective, governments continue to privatize health care and we must step up support for the health care workers and professionals whose demands for increased pay and suitable working conditions are in the public interest.

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Massive Concentration of Decision-Making Power and Union-Busting

– Pierre Chénier –

Nurses in Drummondville protest untenable conditions of work, February 26, 2023.

On March 29, the Quebec government tabled Bill 15, An Act to make the health and social services system more effective. While the society and all health care professionals and workers are demanding that the public health care system be properly funded and the right of the people to health care be provided with a guarantee, the government is handing over the system holus bolus to narrow private interests. It establishes a new chain of command which concentrates decision-making and administrative power in the hands of the ministry along with a hand picked Board of Directors made up of CEOs from private industry to head a new agency called Santé Québec. The multiple bodies and positions Santé Québec is authorized to establish and administer reduce union bargaining units from 136 to four, none of which will be permitted to represent the demands of the people who work in the health care system.

Health Minister Christian Dubé said that he is planning to fill the Board of Directors with "top guns" from the private sector. It obviously sets the stage for the private interests to dictate wages and working conditions and close, merge and further privatize services in the name of efficiency and good management. The public purse will pay higher rates for the private delivery of services and the problem of accountability will only get worse. It is a radical rupture with the public system which at one time was guided by the principle of the greatest good for the greatest number, and All for One and One for All.

Today this has become All for One with the One being the narrow private interests that have no concern for the human factor/social consciousness. Thinking that efficiency has to be achieved by suppressing the human factor and treating workers as disposable will greatly exacerbate the crisis of the provision of services. Modern advances in medicine, which are tremendous, will not make a social contribution so long as a profoundly anti-social policy is pursued of paying the rich and justifying it with self-serving arguments that CEOs of private industry, many of whom have proven to be extremely corrupt, such as those involved in building one of the Montreal mega-hospitals, know what is required and the professionals and workers do not.

The forced reduction of union bargaining units from 136 to four is an ominous sign. It means that locally signed collective agreements, based on the concrete conditions of each region, will be abolished and conclusions will be drawn from statistics which cannot be aggregated to draw warranted conclusions. According to the government, it is acting legally (because it makes the law). It is basing itself on a law in Quebec, adopted under closure 20 years ago, that prescribes the merger of union bargaining units in all health institutions, which then numbered about 200. Then Liberal Health Minister Gaétan Barrette's 2015 reform reduced the number of health care centres to 34 and forced a new merger of union bargaining units at that time -- which did not improve the situation in the health care system. But this is ignored and the conclusion is drawn that it did not go far enough.

The 300-page bill contains 1,180 articles and amends 37 laws. Its character was addressed in the days leading up to its introduction in the National Assembly, by Health Minister Dubé and Premier François Legault. Minister Dubé stated that he would "recruit top guns from the private sector" to lead his reform of the health and social services network that would "shake the pillars of the temple." The media also reported that the Minister addressed some 50 business people who responded to an invitation extended through the Board of Trade of Metropolitan Montreal. They included executives from companies such as IBM Canada, Google Canada, Energir, Accenture, Pharmaprix and KPMG, and the Minister asked them to recommend candidates from their networks to serve on the board of directors of Santé Québec, the agency that will be created by Bill 15.

On March 28, Premier Legault told the media that it is essential to deal with the structure of the health network and that "the success of the approach depends a great deal on the flexibility that we will be able to find in the organization of work." He clearly blamed the unions for the problems of the health care system saying that "local reorganizations can be blocked by local unions. We would like this to no longer be possible, to be able to adapt locally to each situation and make a good reorganization." The reality is that it is thanks to the local unions that the workers are an organized force and have been able to maintain any cohesion of the system whatsoever at a time it has been hanging on by a thread because of the anti-social offensive, lack of funding and the treatment of workers as disposable things. But his hopes of having "reorganizations" unblocked by destroying local unions will not dissuade Quebeckers from becoming an organized force who put the full weight of their numbers and organizations behind their just claims on society.

Nurses in small communities in Nunavik, Quebec, stage sit-in to demand action to deal with staff shortages which prevent them from properly caring for patients, January 20, 2023.

The neo-liberal governments which claim to champion human rights and decry societies which are highly organized to achieve a definite aim as autocracies are in fact bringing in all the autocratic structures to achieve a maximum return on investments in the form of privately appropriated profits. It has nothing to do with achieving returns which enhance the well-being of the members of society and the society itself.

The corruption of the private interests which are plundering the public purse and scamming the system will be revealed sooner rather than later and what the Legault government is up to will be confirmed.

Creation of Santé Québec

Bill 15 establishes the agency Santé Québec. The Health Minister says Santé Quebec will be responsible for operational matters -- the management of the health care system -- thereby permitting the Minister to focus on priorities, objectives and orientations in the field of health and social services and ensure their application. Many have noted that the bill does not mention once that the health care system in Quebec is a public system. Far from it. Santé Québec will be accountable to the Minister, not the Legislature or the public. It will be administered by a board of directors composed of 13 members, appointed by the Minister. There is mention of some form of consultation with the network's internal managers and recommendations from private companies to choose the members of the Board. The wording throughout the bill is that in its role as manager, Santé Québec coordinates and supports both public and private institutions.

The section defining the mission of Santé Québec reads:

"The mission of Santé Québec is to offer, through public institutions, health services and social services in the various health regions of Québec. In those regions, it coordinates and supports, in particular by way of subsidies, the supply of such services by private institutions as well as the supply of services in the field of health and social services by certain other private providers." (Emphasis added.)

Santé Québec becomes the employer, and the sole employer, of the 350,000 workers in the health and social services network. The current employers, the Integrated Health and Social Services Centres (CISSSs) and Integrated University Health and Social Services Centres (CIUSSSs), established in the various regions of Quebec by the Liberal government's 2015 health reform, disappear as entities. Bill 15 establishes a Quebec-wide mega-health institution, as opposed to the 34 CISSSs and CIUSSSs that were each considered an institution.

In the perspective of a single Minister-Board of Directors chain of command for Santé Québec, Santé Québec is responsible for setting up a whole series of organizations governed by it. For example, Santé Québec is responsible for establishing territorial institutions and for governing them. It is also responsible for setting up, among other things, a National Watchdog Committee, a National Program on the Quality of Services, a National Users' Committee, and a Complaint Examination Regime, all of which are accountable to the Board of Directors of Santé Québec.

Not once in this 300-page bill are the voices and demands of health care workers mentioned.

Full-Scale Attack on Unions

The Minister of Health, by establishing Santé Québec as the sole employer of health and social services workers at the head of a Quebec-wide mega health institution, is imposing a restructuring of the unions. By reducing union bargaining units from 136 to 4, many union organizations are slated to simply disappear.

In 2003, the Liberal government passed Bill 30 under closure, which ordered the amalgamation of union certification units in each of the approximately 200 health care institutions. Bargaining units in each facility could only be formed on the basis of one union per category of staff. There are four categories of personnel in the Quebec health care system.

Category 1 includes nursing and cardio-respiratory care personnel. It includes nurses, licensed practical nurses, respiratory therapists and nursing and nursing assistant candidates.

Category 2 includes paratechnical personnel and auxiliary services and trades personnel. It includes, among others, orderlies, housekeepers, food service workers, cooks, service aides, mechanics and trades people.

Category 3 includes office personnel and administrative technicians and professionals. It includes, among others, administrative officers, executive assistants, medical secretaries, administrative technicians, computer technicians and personnel management officers.

Category 4 includes health and social services technicians and professionals. It includes, among others, social workers, social work technicians, human relations officers, community organizers, educators, psycho-educators, occupational therapists, physiotherapists, medical archivists, dietitian-nutritionists, dental hygienists, audiologists and speech-language pathologists.

In 2015, again under closure, the Liberal government imposed Bill 10 which created the CISSSs and CIUSSSs as institutions and employers of health and social services workers, which reduced the number of institutions to 34. This law relied on Bill 30 to impose a new restructuring of the unions. After a raiding campaign, union members in the institutions voted on which union would represent them in each personnel category.

Bill 15 goes further, requiring that there be only 4 union bargaining units in all of Quebec, one for each category of personnel, in the health and social services network, all under one single employer, Santé Québec. In addition, the collective agreements themselves will be reduced to four for the entire network. Already, unions in remote areas have denounced the fact that there will no longer be local collective agreements, which allowed workers in the regions to include clauses that corresponded to their specific conditions.

A president of a union representing nurses in eastern Quebec was recently interviewed by Radio-Canada about the impact of the bill, and said:

"As long as there is only one agreement that applies to the entire Quebec network, how will the Gaspé region, for example, fare in terms of working conditions?"

The bill is introduced in the midst of negotiations for the renewal of the collective agreements in the public which are not going anywhere because the government does not want them to go anywhere. Minister Dubé said at a press conference that he wants the principles of the Bill 15 restructuring to be incorporated into the new collective agreements, without specifying how this will be done.

Service Evaluation and Access to Services

As part of the bill's stated mandate to make the health and social services system more efficient, the government says that it is concerned about service evaluation and access to services. However, its purely statistical approach to the issue reveals an aim to establish indicator tables on the performance of different services according to health facilities and pay no attention whatsoever to the human factor. For example, in a pilot project, the government developed a table of the number of hours people are waiting in a number of emergency rooms before being seen by a doctor. Local facilities are pitted against each other on a statistical basis. The Minister of Health refers to patient experience as a measure to evaluate services and access. In addition, a patient survey regime is established to measure patient satisfaction. A national complaints regime is also established by the Bill in which people submit their complaints to Santé Québec through various bodies established by it.

This statistical approach is denounced by workers because it does nothing to improve their conditions and specifically to solve the problem of attraction and retention of the workforce which is one of the major problems of the health and social services network. Evaluating services and access on a statistical basis does not get to the heart of the matter and suggests that the government and the Board of Directors of Santé Québec could use the data to close or merge services or privatize them.

The legislation has nothing to do with the recognition of health as a right and nothing to do with the recognition of a decisive role for the voice, demands and solutions of those who provide services.

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Previous Restructuring of Quebec's
Health Care System

– Pierre Soublière –

The Quebec government introduced a new health care bill which further concentrates decision-making and implementation of health care services in narrow private hands. Bill 15 is part and parcel of the ongoing take over of the state by private interests. It steps up the anti-social offensive which denies the very notion of a modern society that is accountable to its members and guarantees their rights as human beings and as members of society.

What Years of Restructuring Have Given Rise To

It is useful to put Quebec's Bill 15 in context by recalling efforts by previous Quebec governments to restructure the state to serve narrow private interests. The measures to dismantle the social welfare state and not invest adequately in social programs began to take shape in the early 1980s under René Lévesque's Parti Québécois where the need for reform had become obvious. The issue was what kind of reform should be pursued? Should the reform strengthen the public sector and provide the rights of the people with guarantees or should the need for reform be used to dismantle the public system.

The Liberal government of Robert Bourassa then took over in 1985. It produced, among other things, three reports -- the Fortier, Gobeil and Scowen Reports -- all of which advocated governmental reorganizing by means of privatization, deregulation, dismantling of agencies and outsourcing. The authors of these reports claimed that government, through its state-owned enterprises, intervened in the commercial and industrial realms at the expense of and in competition with the private sector. They upheld that the time had come to re-examine public enterprises and to privatize those services whose mandate could allegedly be taken up more efficiently by the private sector.

In terms of deregulation, the aim was to eliminate all government intervention in the functioning and operations of private enterprises. It was also recommended that small and medium-sized hospitals, as well as state-owned enterprises, be privatized. These reports were based on the premise that state-owned enterprises were inefficient, that the public sector, by nature, was in contradiction with the private sector, and that the space taken up in the economy by the public sector should be made available to the private sector.

The Lucien Bouchard PQ government continued the trend of dismantling the public sector in the name of "zero deficits." Its Public Administration Act among other things, involved downsizing through attrition and its impact continues to be felt today in terms of elimination of staff, loss of expertise and work overload. Bouchard launched his privatization schemes in Lac Saint-Jean, the heart of the Quebec nation, thus also driving a nail into the heart of what had come to be known as Quebec Solidarity. Since then, neither the PQ nor the Bloc have been able to salvage their claim to represent Quebec interests and its has been up to the people of Quebec to fight for the right to health care, education and social services in the face of the brutal anti-social offensive which subsequent governments have pursued. Today the government of the Coalition Avénir Québec (CAQ) continues to privatize health care and use the public treasury to favour private interests. While the Public Administration Act claimed to promote "a new management framework for the public service and improved services for citizens," the CAQ government claims that the aim of Santé Québec is to favour access to health and social services.

Announced in the wake of their 2003 victory at the polls but not mentioned in their electoral platform, the aim of the Jean Charest Liberals' "restructuring" included revising state structures and government programs as well as reorganizing the health system. It favoured calling on experts from the private sector as opposed to public deliberation, dialogue, or negotiation with those involved.

The Liberals' state restructuring later became a "modernization plan." Very much in tune with the CAQ government today, its restructuring was based on the premise that there should be a divide between operational activities and the development of public policies, and a reinforcement of performance management through a contractualization of the relations between administrative units. This new structure of internal governance implied a focus on ministerial powers over policies and orientation.

The declared mission of Santé Québec is to offer health and social services through public institutions as well as to coordinate and support private institutions and "other service providers." The Health Minister is entrusted with functions regarding the priorities, objectives and orientations as well as "certain powers relating to the supervision of the health and social services system."

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Nefarious New Health Act Receives Royal Assent

– Enver Villamizar –

On May 18, the Ontario Ford government's Bill 60, Your Health Act, received Royal Assent. Amongst other things, the new law permits core medical services currently done in publicly funded hospitals, including surgeries and diagnostics, to be delivered by private for-profit hospitals and clinics.

The government has announced that its initial plans are to move 14,000 cataract surgeries to new private day hospitals that it says will be up and running by next fall. It has also announced that it plans to privatize hip and knee surgeries by 2024. Both cataracts and artificial joint surgery require implantation of medical devices -- cataract surgery involves placing an artificial lens, while joint surgery involves a prosthesis or artificial joint. These surgeries provide the private clinics the opportunity to "upsell" from the no longer up to date standard prosthetic implants provided through the OHIP system, with patients offered a "choice" to pay the difference of potentially thousands of dollars.

Bill 60 also privatizes the oversight of the private clinics and deregulates health care staffing including who can call themselves a doctor, a surgeon, a nurse, an MRI technologist, a respiratory therapist and more.

This is taking place as the Ontario government has already announced repeated rounds of tens of millions of dollars for private health clinics, while cutting back on its funding for public health care which in a modern society is duty-bound to address the actual needs of the people and the health care system.

It is also taking place in the midst of determined organizing work of Ontario health care workers which puts forward solutions to the health care crisis. This crisis is caused by the neo-liberal anti-social offensive which diverts money from public programs to pay-the-rich schemes. Subsequent governments have exacerbated the crisis at every turn by attacking the workers with legislated pay caps and limits on what health care workers can negotiate. The aim is to create conditions for an argument on the greater efficiency of privatizing by preventing the workers from addressing problems such as staffing shortages and staff burnout in a manner that favours the workers and the public health care system.

Like in Quebec with Bill 15, An Act to make the health and social services system more effective, the restructuring of the health care system in Ontario on a blatant for-profit basis is coming out of the pandemic and taking place in the midst of negotiations with health care workers for contracts which defend their rights and the rights of patients. Outside of these negotiations the government is making significant changes to the health care system and imposing them as a fait accompli, as if the workers are irrelevant to the actual functioning of the system.

See also "Ontario Government's Reduction of Medical Wait Times by Financing Private Clinics," Barbara Biley and Peggy Morton, TML Monthly, February 2023.

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Ontario Health Coalition Referendum

Throughout the month of May, the Ontario Health Coalition has organized a referendum to give Ontarians a way to express their views on the privatization of health care in Ontario. In person voting is taking place May 26-27 across Ontario at locations organized by 38 Health Coalition chapters.

"Now that Bill 60 has passed, our job at the Ontario Health Coalition is to do everything in our power to stop its implementation. We have to make it politically impossible for the Ford government to privatize our public hospitals," said Ontario Health Coalition Executive Director Natalie Mehra.

To find a voting station near you or to vote on-line click here.

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