The negotiations between Québec’s ruling Coalition Avenir Québec (CAQ) and some 420,000 public sector workers united under the Front commun last year for two seasons of bargaining and massive strike action revealed growing fissures in an overburdened and neglected public health care system. The strain on the public sector has fuelled the wholesale privatization of Québec’s health system, inducing medical professionals to exit the public sector and cynically converting data such as emergency room wait times into evidence of the need for further privatization.

Hospitals in the Outaouais region continued to be flooded over capacity this past winter. Through January, the Hôpital de Hull was operating at close to 200 percent capacity. Local health care and social services centres in small communities like the CLSC Petite-Nation in Saint-André-Avellin have been under particular strain due to a dearth of family doctors and the inability to attract and retain new medical staff. Median wait times at emergency rooms are reportedly longer than five hours, with over 13 hours clocked in some places.

Some of Montréal’s poorest and most quickly gentrifying neighbourhoods like Hochelaga-Maisonneuve, Montréal-Nord and Parc-Ex have long been considered medical deserts, lacking accessible facilities or services. Gaps in areas like psychosocial services and administrative assistance are being filled by community organizations that sometimes become the first contact point with the medical system for the most vulnerable populations.

Decentralized centralization

The Santé Québec Inc. Crown corporation created under Bill 15, which the CAQ government invoked anti-democratic closure to pass, was heavily criticized for being falsely portrayed as a form of decentralization, when it is in fact designed to centralize Québec’s health services.

Regional health care networks see the creation of the Santé Québec agency as leading to a loss of autonomy and institutional diversity, which undermines their ability to address the unique needs of their demographics.

The unions agree and have also slammed the legislation as a tool to expand the role of the private sector and for-profit medicine. The recently appointed CEO of Santé Québec, Geneviève Biron, former CEO of a private sector health group, will be raking in an annual salary of over half a million dollars plus premiums.

As the public sector has struggled to fill positions for health care service aide workers, with a shortage of over 2,000 reported in 2022, the CAQ has continued rolling out telemedicine and digitization. As per Québec’s recent budget, the CAQ will be spending $902.5 million over a five-year period on the digital transition of the health care system.

In a sector where personal intake, treatment and care are fundamental to wellbeing, trust and security, many tough questions can and have been raised regarding the much touted promises of digital health. For one thing, digitalization of medical appointment scheduling and access to services may make it harder for people who are unhoused, living in poverty or on low incomes, to obtain care from the public health system. Without basic access to the internet and laptops, or compatible models of phones, they may be unable to fill out forms and schedule appointments through online booking systems like Québec’s Clic-Santé.

Digitization has also given rise to a fair amount of controversy around the accountability of contracted service providers. The 2021 class action suit against Innovation Tootelo Inc. speaks to the ways in which ‘entrepreneurial solutionism’ has exploited administrative gaps for public access to the health care system.

Tootelo created the digital application Bonjour-Santé which gives users access to health services covered by the Régie de l’assurance maladie du Québec (RAMQ), Québec’s public health insurance program. It developed the app in a format that stratifies levels of access, with monthly subscriptions giving “unlimited” and “exclusive” access to services like appointment booking and renewals for contraceptives, as well as to private medical services like Clinique Praxis and assessments using AI-based tools.

The lawsuit was filed on behalf of people who paid to obtain appointments for acts insured by RAMQ on the grounds that they were charged accessory fees prohibited by the Health Insurance Act.

With private enterprises seeking to exploit the need for digital access to health services and capitalizing on Québec’s exploding AI sector, privately operated health services are steadily becoming normalized across the province.

An apparently utilitarian move to clear waiting lists for surgeries has fuelled the growth of the private sector, with contracts awarded by public hospitals to private clinics exceeding $100 million in 2021. According to data from the Fraser Institute, one in six government-funded surgeries in Québec is performed in private clinics.

These clinics include national corporate chains like Clearpoint Health Network, which expanded to an operating room centre in Brossard in December 2022. The number of these private clinics in Québec has grown to 73 in the past year, with costs for private surgeries up to 150 percent higher than in the public sector.

The CAQ’s proclivity for privatization is apparent in its plan to develop two private mini-hospitals: a geriatric hospital in Montréal and a paediatric hospital in Québec City. Anne Plourde, a researcher at the Institut de recherche et d’informations socioéconomiques (IRIS), Québec’s left-wing social policy think tank, has compared these mini-hospitals to the so-called super clinics inaugurated by Québec’s former Liberal Party Health Minister Gaétan Barrette in that they only serve the interests of private investors without actually addressing the crisis of care facing the province.

Private sector placement agencies that emerged in Québec during the pandemic as a temporary measure have also become normalized. This includes companies like Nomadic Nurse Agency and MON+, which place nurses in clinics in Montréal and Québec, as well as Québec’s regions and the far north.

Contract workers for these temporary staffing agencies are not unionized and pay grades are not transparent, but dismal conditions in the public health sector have created an exodus toward such private agencies.

Meanwhile, public spending on private enterprises has contributed to Québec’s historic deficit: the CAQ reported a deficit of $11 billion this March—the sixth worst in Québec’s history. The government spent more than $1.5 billion in 2022 alone on private agency health care workers and remains dependent on them, according to CAQ Health Minister Christian Dubé.

In response to heavy criticism of the public sector’s continued dependency on private placement agencies, Dubé’s Bill 10 has committed to restricting their use by 2026. However, temporary workers would continue to be contracted by private clinics, which are flourishing to the detriment of the public sector.

Stockholm syndrome

While episodic reports of for-profit medicine in Québec bring attention to the erosion of disparate areas of the universal health care system, privatization has long been billed as a solution to the public “monopoly” on health care.

The Montréal Economic Institute (MEI), Québec’s answer to the Fraser Institute, has been promoting the ideology of deregulation and free-market policy in Québec for four decades. Though the think tank does not reveal its funders, its leadership and directors belong to Canada’s business elite, and the oil and gas industry represents its second biggest source of funding.

The MEI’s papers and reports attribute such critical problems as the shortage of physicians and long ER wait times to the “absence of competition between private and public providers,” contradicting the public image of private medicine “complementing” the public health sector.

Advocating for the overhaul of Québec’s health care system, the MEI has touted the Swedish and UK models of health care reform, which have largely revolved around the private delivery of public health care services, as examples for Québec to emulate.

The MEI presents the St. Göran hospital, a privately owned emergency hospital in Stockholm, as a perfect model of health care “managed by entrepreneurs” while operating within the public sector. With the “Stockholm model,” the MEI points out, “the patient becomes a source of income.” It stresses that patients at St. Göran are “not expected to pay for the care” because the hospital operates within the public sector and services are financed by the Stockholm County Council.

Such blurred lines between the public and private sector open pathways for corruption. As political economist and health policy researcher Andrew Longhurst has argued, Québec’s Bill 15 has followed Alberta’s failed example, where expanding private surgical provision “came at the expense of hospital staffing and resources, which shrank on a per capita basis.” Longhurst also cited the unlawful billing of patients in British Columbia. The BC Health Coalition reported $18.1 million in illegal charges between 2021-22 for medically necessary services that should be available at no cost.

This has also been a practice at the McGill University Health Centre (MUHC). Prior to the sudden closure of a children’s clinic at the MUHC in January, doctors who were working simultaneously in the public and private health sector were charging for allergy and blood tests that should have been covered by RAMQ.

The MEI fails to mention that, today, Sweden’s health care system is struggling under the weight of a huge deficit and that grassroots movements like PHM-Scandinavia have long resisted the systematic dismantling of the public health sector with movements like Occupy Our Hospitals that saw mass mobilizations of activists occupying hospitals in Sollefteå and Dorotea.

The drive to privatize

Far from being complementary to the public sector, public-private partnerships end up costing the public more. Médecins québécois pour le régime public (MQRP), an organization of health care professionals dedicated to maintaining the public system, has criticized this model in Québec’s Groupes de médecine de famille (GMFs), which are publicly funded but privately managed groups of family doctors.

The MQRP also sees these facilities as enabling private management to renounce accountability for surgical malpractice within the public system.

As GMFs have developed across Québec over the past two decades, these public-private enterprises have come to replace democratically-run CLSCs to provide health care. But research has shown that GMFs are not fulfilling their mandate to improve access to family doctors, relieve the burden on emergency waiting rooms, and improve access to psychosocial services.

Plourde has also reported that the public-private system, which frequently splits contracts for health workers between CLSCs and GMFs, leaves patients falling through the cracks. Transfers of personnel from public CSLCs to privately-run GMFs has excluded patients from services with CLSC staff when they are not already registered with family doctors at GMFs.

Plourde’s research documents the historic deterioration of Québec’s public health system, drawing parallels between the current privileging of the private sector and the neoliberal reforms that began to burgeon under Robert Bourassa’s Liberal government in the mid-1980s. During its previous term in the first half of the 1970s the Bourassa government established universal health care in the province. A critical moment in this paradigm shift on Québec’s public health system was a 1986 report submitted to the Bourassa administration by the Comité Provigo, which proposed the privatization of hospitals and the dismantling of CLSCs.

During massive nurses’ strikes in the 1990s, the public health system was so overstretched that Québec was sending patients to the United States for radiation treatment amid funding cuts by the Parti Québécois.

The current approach that relies on public-private partnerships, and shuttling patients out of the public sector toward private clinics, was initiated by former Premier Philippe Couillard’s Liberal administration. Health Minister Gaétan Barrette was criticized for paving the way toward “disguised privatization” with a pilot project in 2016 that awarded $4 million to three private surgery clinics for “direct and indirect” costs of serving patients from the public sector.

Today, the dependency on private-sector agencies and subsidization of private enterprises shows that this deliberate fracturing of the public health sector is advancing apace, with the pandemic having served to accelerate the process.

Critics agree that the CAQ’s reforms have politicized health care, treating it more and more as just another market sector rather than a social good. ‘Entrepreneurial solutionism’ is transforming health care into a commodity to be exploited by venture capitalists and made available differentially to those who can afford it, rather than a right that is protected by the Universal Declaration of Human Rights as well as international treaties on the right to physical and mental health.

Whether Québec’s deteriorating public health system is rightly viewed as a humanitarian crisis and becomes a decisive issue in the 2026 election remains to be seen. In the meantime, illness has never been more profitable.

Lital Khaikin is a freelance journalist and author based in Montréal, and regularly contributes features on humanitarian and environmental issues related to underreported regions and conflict zones.