Claude Castonguay, former Minister of Health and Social Alliance of Québec, Canada, regarded as one of the founding fathers of Québec’s healthcare system, discusses his achievements within the healthcare space, his thoughts on the current healthcare reforms under way in Québec, and his conviction of the benefits of decentralization for Québec’s healthcare system.
Claude, you are widely acknowledged as one of the founding fathers of Québec’s healthcare system along with many other achievements. Could you briefly outline your career within this space?
First and foremost, I trained as an actuary and during my studies, I had been very interested in social insurance initiatives like Social Security in the US and the initiatives proposed by the Beveridge Report in the UK. In the early 1960s, when a number of policy changes were taking place in the Province of Québec, I was first involved in the broad question of pensions – a topic I was very familiar with. I was then also actively involved in the establishment of a universal pension plan. In Québec, we developed our own Québec Pension Plan and we made sure it integrated into the Canada Pension Plan. That was my first experience with social policy. I led the drafting of a report, whose recommendations were adopted, and I was also involved in negotiations with the Federal government. Both pension plans are still operating today, and quite successfully, I would say, 50 years later.
Thereafter, it was clear that health and medical care insurance was coming to Canada and Québec. I was asked by the government then to head a commission on health care and social services. There was very little information or documentation available then, so we spent three years researching and eventually produced a ten-volume report. The so-called Castonguay-Nepveu Report was published in 1970 and recommended a new state-run health insurance program, a new health care network, as well as a new network of social service clinics now known as the CLSC.
Subsequently, there was an election in Québec and I was asked to run by Jean Leage*, then leader of the Liberal Party. We were elected and formed a new government made up of young people. I was 41 and probably in the mid-range! I was appointed Minister of Health and of Family and Social Welfare. We then merged the two ministries, introduced health and medical coverage and established the basis for the current healthcare system. The basic legislation is still in place; we had kept it relatively simple at that time because I felt that it was best for us not to try to organize every single detail. The legislation has since been expanded and now provides for much more regulation of the system.
After I left the government, I went back to my profession and was very active until my retirement in 1990. I then did some consulting work before being appointed to the Senate of Canada. In 2007, I was asked by the minority Liberal government in Québec to undertake and lead a few studies. This led to the introduction of the pharmaceutical drug coverage program, which is quite unique in Québec as there is no equivalent in other provinces. In another study in 2008, the taskforce I headed published another report on the finances of the health system, in which we recommended the creation of an institute of health excellence based on what existed in the UK and France.
Today, the current Minister of Health and Social Services of Québec Dr. Gaétan Barrette has implemented a number of sweeping reforms that you have publicly disagreed with. What are the fundamental issues at stake here?
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The original approach was to have a decentralized system where decisions could be made at the proper level depending on the issues, where people could be clearly responsible and accountable for certain functions, and where the necessary changes and innovations could be introduced readily. Québec’s healthcare system was based on hospitals with their own boards possessing a good degree of independence and autonomy, as well as well-defined missions, and providing quality services.
That was the idea. We wanted to have, as much as possible, the cooperation of doctors and nurses. We felt that the healthcare system as a whole should be run on the basis of cooperation and negotiation. That has been the pattern followed pretty much until the current government. The results have on the whole been quite reasonable and the outcomes have been good, with the exception that too much emphasis has been placed on hospital care. This was a result of the fact that hospital services are covered by hospital insurance, so Québec citizens are more inclined to use them instead of primary care and prevention initiatives. We introduced a good, functioning first-line primary care organization but the system has not adapted properly when it comes to primary care access.
Today, government bureaucracy has become too involved in trying to manage the system from Québec City. The Ministry of Health is the largest public organization in Québec. The current Premier used to be Minister of Health for five years so he should have a great understanding of that complexity of the Ministry. The current Minister of Health, Dr. Barrette, was the head of the Féderation des médecins specialists du Québec (FMSQ), the federation for medical specialists, which advocates on behalf of doctors’ interests. The FMSQ is a much smaller organization than the Ministry of Health and the same leadership style or approach Dr. Barrette may be used to – which is very centralized – is not suitable. He has centralized decision-making power to a degree unknown in Québec, and probably never attained in any other province.
Instead of working to get cooperation, he has taken a very aggressive attitude and imposed his way of thinking and what he believes should be done instead of collaboration and negotiation.
In our interview with him, Minister Barrette stressed that sometimes a more top-down approach is more effective than a gradual, collaborative approach when it comes to driving change. To what extent do you agree with this?
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There is always a balance in government. If you simply follow the interests of stakeholder groups and public opinion, there is a limit to what you can do. Quite often, the majority of the population does not understand the complex issues at stake here. This is why a government has to sometimes lead and take the initiative on policy issues. But there is a fine balance to be established. I believe Minister Barrette has taken a very aggressive attitude towards healthcare professionals and administrators, and has imposed his way of thinking on them instead of negotiating to reach suitable understandings. This is simply not done. Healthcare professionals do want to have a degree of autonomy and responsibility over their actions and careers.
Nevertheless, both you and Minister Barrette share the idea of achieving ‘integrated care’. Is this more achievable through incremental steps or radical reforms?
Neither. Québec has a variety of healthcare institutions at the moment. We have the CLSC, dealing with prevention and home care, who are doing quite a good job. Many doctors run their own private clinics. A few years ago, a new concept, the ‘groupe de medicine de famille’ (GMF) was introduced, which followed a very strict, regulated model. It is not clear what Dr. Barrette’s proposal of ‘super clinics’ will add to the current system. Super clinics are supposed to offer the same services as GMFs but with additional requirements like having to stay open for 12 hours a day, 7 days a week, and to offer everyone an appointment within 2-3 days.
In my opinion, such changes cannot be imposed; people will have to be provided incentives to organize clinics according to different patterns as required by population needs. Any healthcare system should have more than just one type of clinic to fulfil the diversity of population needs.
Furthermore, another issue is that the current financing of GMFs is provided through an increase in the remuneration of family doctors instead of directly to the clinics’ operations and services. The family doctors themselves decide how much they will allocate to clinical operations, and typically, they are not as interested in funding additional programs like nursing or technical services. There are improvements to be made but they need to be negotiated with the buy-in of the healthcare professionals involved.
Québec’s healthcare system stands apart from other provinces as it has its own regulatory entities and practices, as well as market characteristics, such as a rapidly aging population. In what sense can Québec lead the rest of Canada in terms of health reforms and best practices?
I do not think we can – or should – pretend we are better than the others. But in a decentralized system, where individuals and organizations can develop their own abilities and best practices, it can bring positive innovations and initiatives that may be of interest to other provinces. Putting everybody in the same mold or structure, in my opinion, has a negative impact on innovation and imagination.
Québec has been very progressive in introducing innovative social policies. For instance, we have introduced an educational program for very young children to meet their early childhood needs pre-schooling and also allow their mothers to return to the workforce. Québecois society is very much inclined towards solidarity and community health; for instance, we are much more developed in terms of social policy than the US. This is how we can bring value to other societies.
On a separate note, there has been debate on the establishment of a national pharmacare for years now. How realistic do you think this is – either on a Federal or provincial level?
Québec has a public/private system covering all citizens. This is due to the fact that the government could not have introduced a public system for the entire population. The increase in taxation required would not have been viable, and would have made Québec’s employers very uncompetitive. It was felt that since most corporations have drug coverage programs, the best option would be to leave the private system in place but subject to regulations to ensure they meet certain standards. The public system covers drugs for specified subsets of populations, which required only a limited number of adjustments and a modest increase in public spending.
When you look at the question now with regard to a national program, you have the same problem. What would a national pharmaceutical program cost? What would it add to federal public spending? It is clear that huge amounts of money would be required. No province has gone beyond catastrophic kind of coverage, none has introduced a public plan … the Federal government has been discussing this issue since 1970 when the coverage of medical care was completed for the whole country. For nearly half a century, no government has found the way to implement a national public program.
Would it be possible to have a more comprehensive catastrophic kind of coverage for a greater segment of the population? Possibly. But this is not really being discussed actively as far as I know. The question of a national drug program comes up on and off but nothing has happened and we are not close to seeing anything concrete happen.
Looking forward, what do you expect for the Québec healthcare landscape in the next few years?
We will have a provincial election in October 2018. Healthcare will certainly be a hot issue because people are not satisfied with the current primary care situation, and they know that there are other pressing issues like a lack of hospitalization services, a lack of sufficient home care as well as the pressures of an aging population. The Liberal government has been in power for most of the past 15 years, so it is difficult for them to claim that they are the best party to drive healthcare reforms –especially as the general public sentiment seems to be against the changes implemented by Dr. Barrette.
Nevertheless, I do not believe the next election will be decided on specific promises or commitments. As our only female Prime Minister, Kim Campbell, once said, an election campaign is not the proper time to discuss serious issues. People will go toward the party that represents the best guarantee of being able to positively reform the existing healthcare system through the establishment of a proper dialogue with all those concerned.
