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THE DIFFERENTIAL IMPACTOF HEALTH CARE PRIVATIZATION

ON WOMEN IN ALBERTA

C. M. ScottT. Horne

W. E. Thurston

PRAIRIE WOMEN’S HEALTHCENTRE OF EXCELLENCE

R E S E A R C H P P O L I C Y P C O M M U N I T Y

Administrative Centre:

Prairie Women’s HealthCentre of Excellence

The University of Winnipeg515 Portage Avenue

Winnipeg, MB R3B 2E9Telephone: (204) 786-9048

Fax: (204) 774-4134E-mail: [email protected]

Regina Site:


University of Regina ExtensionRegina, SK S4S 0A2

Telephone: (306) 585-5727Fax: (306) 585-5825

E-mail: [email protected]

Saskatoon Site:


University of SaskatchewanSaskatoon, SK S7N 5E5

Telephone: (306) 966-8658Fax: (306) 966-7920

E-mail: [email protected]

WEBSITE: www.pwhce.ca

The research and publication of this study were funded by the Women’s Health Bureau of Health Canada, theWomen’s Health Research Group at the University of Calgary, and the Prairie Women’s Health Centre of Excellence(PWHCE). The PWHCE is financially supported by the Centre of Excellence for Women’s Health Program,Women’s Health Bureau, Health Canada. The views expressed herein do not necessarily represent the views of thePWHCE or the official policy of Health Canada.

THE DIFFERENTIAL IMPACT OF HEALTH CARE PRIVATIZATIONON WOMEN IN ALBERTA

C.M. Scott, T. Horne and W.E. Thurston

©2000 C.M. Scott, T. Horne, W.E. Thurston, and the Prairie Women’s Health Centre of Excellence

ISBN 0-9684540-7-0

ORDERING INFORMATIONThe full text of this report will be available on thePWHCE website at www.pwhce.ca in the summerof 2000. Additional print copies are available bymailing a cheque or money order for $10.00 inCanadian funds to:

Prairie Women’s Health Centre of ExcellenceRoom 2C11A - The University of Winnipeg

515 Portage AvenueWinnipeg, MB R3B 2E9

Contents

THE DIFFERENTIAL IMPACT OF HEALTHCARE PRIVATIZATION ON WOMENIN ALBERTA

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . i

Executive Summary . . . . . . . . . . . . . . . . . . . . . . ii

PART 1: INTRODUCTIONGender-Based Analysis in Alberta . . . . . . . . . . . . 2The Evolution of Alberta Health and Social Policyin the Canadian Context . . . . . . . . . . . . . . . . . . . 6Public Participation . . . . . . . . . . . . . . . . . . . . . . 11

PART 2: PRIVATIZATION OF HEALTH CAREIN ALBERTA 1989-2000The Current Vision for the Health of Albertans . 15The Provincial Platform: Key Policy Initiatives . . 161. The Rainbow Report . . . . . . . . . . . . . . . . . . . 162. Partners in Health . . . . . . . . . . . . . . . . . . . . . 183. Starting Points . . . . . . . . . . . . . . . . . . . . . . . . 194. Health Goals for Alberta . . . . . . . . . . . . . . . . 215. The Regional Health Authorities Act . . . . . . . 21

6. The Delegated Administration Act and The Government Organization Act . . . . . . . . . . . 247. A Better Way (I) . . . . . . . . . . . . . . . . . . . . . . 258. A Better Way (II) . . . . . . . . . . . . . . . . . . . . . 269. Action on Health . . . . . . . . . . . . . . . . . . . . . 2810. The Health Statutes Amendment Act . . . . . . 3011. Health Summit ‘99 . . . . . . . . . . . . . . . . . . . 3012. Health Information Systems: The Health Information Act . . . . . . . . . . . . . . . . . . . . . . 3113. Bill 11: The Health Care Protection Act . . . . 3214. Community-based Care and Home Care . . . 37

PART 3. CONCLUSIONS . . . . . . . . . . . . . . . . . 40

Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

i

Acknowledgements

We would like to express our thanks to Phil O’Haraand Erin Rutherford for the commitment, energy andinsight that they brought to this project.

We would also like to thank the Centres of Excellencefor Women’s Health Program (Women’s HealthBureau, Health Canada); the Prairie Women’s HealthCentre of Excellence; the Women’s Health ResearchGroup, University of Calgary; and the NationalCoordinating Group on Women and Health CareReform for providing encouragement and financialsupport.

Cathie Scott, MScGraduate Student, Community Health Sciences

University of Calgary3330 Hospital Drive NW

Calgary, Alberta T2N 4N1 Director, CST Consulting2907 - 13th Avenue NW

Calgary, Alberta T2N 1M1P: (403) 284-9718F: (403) 289-2619

E: [email protected]

Tammy Horne, PhDWellQuest Consulting Ltd.

11511 - 125th StreetEdmonton, Alberta T5M 0N3

P: (780) 451-6145 F: (780) 451-5280E: [email protected]

Wilfreda E. Thurston, PhDAssociate Professor, Community Health SciencesUniversity of Calgary - 3330 Hospital Drive NW

Calgary, Alberta T2N 4N1P: (403) 220-6940 F: (403) 270-7307

E: [email protected]

ii

Executive Summary

THE DIFFERENTIAL IMPACT OF HEALTHCARE PRIVATIZATION ON WOMENIN ALBERTA

BACKGROUND

The Prairie Women’s Health Centre of Excel-lence is a member of the National CoordinatingGroup on Health Care Reform and Women. TheCoordinating group is comprised of representa-tives from the five Centres of Excellence forWomen’s Health, the Canadian Women’s HealthNetwork, and the Women’s Health Bureau ofHealth Canada. It has developed a framework forinvestigating the impacts of health reforms onwomen to guide researchers’ efforts to monitorthe effects of health reforms on women—as pa-tients and service recipients, as paid and unpaidhealth care providers, and as participants inhealth policy discussions.

As part of this national project, the Centres con-ducted provincial and regional scans of policiesand research related to privatization in healthreform and its impacts on women. The PrairieCentre conducted the Manitoba and Saskatche-

wan scans in 1999. The recent commissioning ofthis report by the Prairie Centre, and a similarexamination of Newfoundland under the auspicesof the National Network on Environments andWomen’s Health, completes the coverage of pro-vincial jurisdictions in the scans.

The National Coordinating Group hopes to fostercollaboration and encourage other health resear-chers and women’s health organizations to takeup the challenge of monitoring the impacts ofhealth reforms on women and women’s respon-ses to health reforms.

OVERVIEW

The purpose of this paper is to explore the extentto which health care privatization is taking placein Alberta and to determine the impact of healthcare privatization on women. To do this, we useda gendered lens to examine a number of key pro-

THE DIFFERENTIAL IMPACT OF HEALTH CARE PRIVATIZATION ON WOMEN IN ALBERTA

iii

vincial health policy documents. The review wasconducted between February and April 2000. Itwas beyond the scope of this project to directlyexamine the impacts of health care privatization;no new data were collected. While this report isnot intended to provide a complete review of allpolicy related to health care privatization, it prov-ides an overview of policies and initiatives thatexemplify of the Alberta government’s policyplatform.

This report traces the development of health pol-icy initiatives from 1989 to the present,demonstrating that there has been consistent sup-port for increasing the role of the private marketin Alberta’s health care system. Privatizationtakes several forms - shifting service delivery outof public institutions such as hospitals to privateclinics, shifting costs of services from govern-ment to individuals, shifting caregiving workfrom public sector health workers to unpaid care-givers and adopting the management strategies ofprivate sector business.

There has been a perception among many peoplein Alberta that health care restructuring was initi-ated and continues without having an overall planin place. While there may have been a lack ofclarity regarding specific strategies for change inthe health system, there has been a consistentcommitment to increasing the involvement of theprivate sector in health care financing (e.g., outof pocket costs) and delivery (e.g., services deliv-ered through for-profit clinics, work for familycaregivers, particularly women). This commit-ment has not wavered, despite the equally consis-tent expression of public concern regarding thepotential negative impact of health care privatiza-tion.

The shift to more privatization in health has beenaccompanied by resistance to acknowledging thedetrimental impacts of privatization, particularlyon women. Women are providing more servicesat home, in the not-for-profit organizations, andwith less support. Women working in services inAlberta know that, as elsewhere, the genderedimpacts of restructuring are not evenly distrib-uted among women, and that young women, im-migrant women, women of colour and workingclass women have been hardest hit. Restructuringhas been linked to the intensification andfeminization of poverty for young and elderlywomen in particular.

The government’s commitment to privatizationof the health system has also been accompaniedby a trend toward increasingly limited and con-trolled public participation in the planning pro-cesses. Legislative and public opposition to thecurrent privatization policy agenda has done littleto alter the course or the pace of change. Giventhe government’s apparent lack of responsivenessto public input, it is not surprising that there ap-pears to be a great deal of skepticism among Al-bertans regarding their ability to influence thepolicy process. This was illustrated againrecently during public discourse around Bill 11,which permits increased private sector involve-ment in the health system. As well, Albertansmust now deal with 17 regional health authoritieswhen it comes to organizing around health poli-cies that affect them at the local level, rather thanbeing able to deal with a central provincial struc-ture.

PART

1 INTRODUCTION

The purpose of this paper is to explore the extentto which health care privatization is taking placein Alberta, and to determine the impact of healthcare privatization on women. The review wasconducted between February and April 2000. Itwas beyond the scope of this project to directlyexamine the impacts of health care privatizationin Alberta; no new data were collected. Whilethis report is not intended to provide a completereview of all policy related to health careprivatization, it provides an overview of policiesand initiatives that exemplify of the Albertagovernment’s policy platform.

Gender is a culturally determined symbol-systemused to understand and organize human behav-iours (Mackie, 1991). Gender-based analysis(GBA) assesses the implications of culturally-defined roles for policy implementation and eval-uation. Gender-based analysis of health and so-cial policy raises issues that are otherwise ob-scured in analyses that are purported to begender-neutral, issues that have major implica-tions for the goal of equity in policies and pro-grams. The impetus for gender-based analysesoriginated in the women’s movement and femi-nist theory as a response to women’s low statusin society, and the social problems experiencedby women and their children. Recent theoreticaladvances have recognized the diversity amongwomen, and the need to consider interlocking

systems of oppression (e.g., racism, ablism,homophobia, classism). Gender-based analysis,therefore, is about understanding how privilege ismaintained, as well as how disadvantage is cre-ated. Though a complete gender-based analysisincludes examining the impact of policies on menas well as women, the primary focus for thisreport is women.

For the purposes of this paper, we have adopted abroad conceptualization of privatization whichincludes:

P privatizing the costs of health care by shiftingthe burden of payment to individuals;

P privatizing the delivery of health care servicesby shifting care from public institutions tocommunity-based organizations and privatehouseholds;

P privatizing carework from public sector healthcare workers to unpaid caregivers; and

P privatizing management practices within thehealth system by adopting the managementstrategies of private sector businesses(Willson and Howard, 2000).

This definition moves beyond a limited onewhich focuses on movement into private businessownership and purports to be gender-neutral, butignores important realities of women’s and men’slives.


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Horne, Donner and Thurston (1999) reviewedtools for applying gender-based analysis withinthe health sector, developed a framework andapplied it to policy documents in Manitoba andSaskatchewan. They recommended that both pro-cesses and policy or program content be assessedfor gender sensitivity. The following are keyissues in each category:

Processes

1. representation of women in policy decisionmaking and in leadership roles within thehealth sector (e.g., employees, board mem-bers);

2. inclusion of men as well as women in redress-ing inequities and promoting women’s healthand equality;

3. availability of training in women’s health andgender issues (in both practice and research)for both decision makers and staff;

4. use of inclusive public participation pro-cesses that take differential barriers to partici-pation into account (e.g., child care, language,disability);

5. links to women’s organizations and othersources of expertise in gender analysis, aswell as other equity seeking organizations(e.g., Aboriginal);

6. inclusion of women in research, both as par-ticipants and as decision makers;

Content

1. recognition of the differential impact of socialcontext on health (i.e., social and economicfactors);

2. assessing whether the focus on women’shealth is inclusive (e.g., reproduction, role asmothers, conditions specific to women);

3. gender sensitivity in all programs, not justthose specifically for women;

4. the focus of outcomes, equality rather thansameness of activities or treatment and inclu-siveness of indicators of success (i.e., anequity approach);

5. equitable distribution of resources, access andquality of services;

6. dis-aggregation of data by sex and other de-mographics; and

7. the impacts of health policies on family mem-bers through unpaid care-giving and out-of-pocket expenses.

We will use this framework to guide our analysisof provincial policies and explore the socio-political context within Alberta and how it hasdefined the current discussion of health care re-form in Alberta. In Part 2, we will conduct a de-tailed gendered analysis of the privatization ofhealth care in Alberta. We will conclude the pa-per with a discussion of the implications of theanalysis in Part 3.

GENDER-BASED ANALYSISIN ALBERTA

In this section, we review evidence concerningthe current level of gender-based health policyanalysis supported by the Alberta Government.While our focus is health reform, some relevantreports look at more general public policy. Wewill then highlight some of the other sources ofgender-based analysis in the province (Albertahas a large number of local women-focussedgroups, many of which are explicitly feminist,and other groups with specific interests, such aslesbian rights, interests of women of colour, im-migrant women, professional women).

Linda Trimble (1997) examined the Alberta Leg-islative debates between 1972 and 1994 to deter-mine whether a critical mass of women made adifference in having women’s concerns


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addressed within the parliamentary system.Trimble’s systematic analysis of the AlbertaHansard index demonstrated that “under certaincircumstances, female legislators can make a difference” (p. 151). In particular, she noted theimpact of female MLAs raising issues and edu-cating colleagues from all parties:

Before 1986, six governing-party women hadlittle effect, while Opposition men (and oneTory backbencher) occasionally raisedgender-equality issues. The 1986 electionbrought four Opposition women to the legisla-ture, and these women had a significant impacton the tone and direction of debate. They intro-duced feminist analysis of a wide range of is-sues, analysis which was adopted by their malecolleagues in the Opposition ranks (Trimble,1997, pp. 151-152).

Between 1986 and 1993, female MLAs cooper-ated across party lines to bring women’s issues tothe table. Since 1993, however, this level ofcross-party cooperation has all but disappeared.Although the ruling Conservative caucus in-cluded several women, these women publiclysupported their party’s economic and social pol-icy agendas (Trimble, 1997). The governmentposition was that deficit reduction measures weregender neutral “despite evidence to the contrary”(p. 151), and consistently resisted taking genderinto account as part of policy formulation. Hav-ing several women in caucus was not sufficientto make gender-based analysis a reality, but wehave no way of knowing if or how they moder-ated the decisions and the potential impacts onwomen and children. We do know that the envi-ronment became more anti-feminist in the lastdecade. Although the current provincial govern-ment has had a number of high-profile femaleministers over the last seven years (1993 to2000), including the former Minister of Health(Hon. Shirley McClellan) and the Minister with-

out Portfolio who co-chaired the Health PlanningSecretariat (Hon. Dianne Mirosh), these womenhave tended not to take a feminist perspective,and in some cases, have been overtly anti-femi-nist.

A major barrier to incorporating gender-basedanalysis into the discourse on health privatizationin Alberta, therefore, is the provincial govern-ment’s history of anti-feminism and the pejora-tive labelling of women’s organizations and oth-ers critical of government policy as “special in-terest groups,” or more recently, as “left-wingnuts.” Dacks, Green and Trimble (1995) note thatsome members of Caucus have been publiclyaligned with the Alberta Federation of WomenUnited for Families, a group that supports tradi-tional patriarchal family roles for men andwomen, and is opposed to any policy that ques-tions those traditions (e.g., child care programs,pay and employment equity). Dacks et al.(1995)also cite several examples from Hansard andMLA quotes from the Edmonton Journal thatsuggest negative attitudes toward women who donot stay at home or live in nuclear families (e.g.,that kindergarten has become a substitute for daycare; that a mother was to blame for the rape ofher six-year-old daughter by a babysitter; thatmost women want to go back home and promotethe family unit; that women seeking child sup-port maintenance enforcement are “vindictiveleech moms”).

Dacks et al. (1995) note statements from the1993 Premier’s Council on Alberta Families thatsuggest that it is most desirable for families to besupported by one income, and that some familiesbecome two-income households by choice ratherthan by economic necessity, as though the latteris the only value of employment. These authorsinterpret the Premier’s Council’s vision (and itsconnection to government policy) as follows:


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Such a family should be supported by a singlewage earned by the father and the unpaid la-bour of the mother in the home and commu-nity. This vision is at the heart of the so-calledAlberta Advantage, for it helps governmentexploit the unpaid labour of women in order toreduce the public sector and shrink governmentspending. The government can then attractbusiness and investment to Alberta by passingalong the “saving” to corporations via incen-tives and tax reductions (Dacks et al., 1995, p.280-281).

Despite government rhetoric about the impor-tance of single-income families and full-timeparenthood (motherhood), Teghtsoonian (1997)points out that support for such policies is limitedto economically privileged heterosexual nuclearfamilies. She notes that such encouragement isnot provided to lesbian or gay families, or tofamilies on low incomes or receiving social as-sistance (where there is an expectation that moth-ers should be in paid employment rather thancaring for children full time). This disrespect forwomen’s concerns and the anti-feminist, pro-family agenda is a barrier to incorporatinggender-based analysis into health planning ingeneral and privatization in particular.

Further evidence of the government’s lack ofinterest in hearing about gender analysis is thedismantling of the Alberta Advisory Council onWomen’s Issues (AACWI). The Council, in exis-tence from 1986-96, was intended to be arm’slength from government and to identify issues ofconcern to women. AACWI’s main roles were toconduct research, to make recommendations togovernment, and to consult with and providefeedback to the public. The Council commis-sioned 13 research reports and discussion papers,but of the 86 recommendations put forward bythe government, only seven were accepted(AACWI, 1996a). In the last two years of its

mandate, it became increasingly clear that theCouncil work was not well-received by the gov-ernment (e.g., specifically discussed and appliedgender-based analysis to determine the differentialimpact of the government’s economic policies—the so-called “Alberta Advantage”—on women andmen (Kerr, 1995). In her discussion of health care,she noted that women are more likely to be disad-vantaged by funding cuts through the loss of well-paying jobs in the health sector as well as by in-creased expectations for unpaid care-giving as ser-vices shift to commu-nity settings. She also cited anumber of govern-ment recommendations thatwould raise home care and long-term care usercharges, income-dependent rather than universalcoverage of se-niors health benefits, and increasedhealth care premiums. Dacks, Green and Trimble(1995) not-ed that a number of MLAs began ques-tioning fund-ing to AACWI shortly after the 1993election. In 1996, the provincial government an-nounced its in-tention to invoke the sunset clausethat would see the Council eliminated nine monthsbefore the end of its mandate (Alberta AdvisoryCouncil on Wo-men’s Issues, 1996b).

Academics, women’s health organizations, region-al health authorities, unions, and others have alsoconducted gender-based analyses despite the gov-ernment’s lack of interest. Dacks et al. (1995)pointed out that Alberta’s deficit reduction initia-tives—cutting health, education and social ser-vices—have hurt women most. Women benefitfrom the welfare state both as service recipientsand as employees, and public sector em-ploymenthas contributed to many women’s economic inde-pendence. Dacks et al. cite public sector union sta-tistics indicating that more wo-men than men suf-fered job losses in 1993 and 1994, as more of theemployees were female. They note that job lossesby women in the public sector have two effects:women are forced to look for work in the privatesector (usually for lower pay, security and


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benefits); and they com-pensate for loss of publicservices by providing unpaid labour to take upthe slack (e.g., more care-giving as hospitals ad-mit fewer patients and release patients sooner).

A qualitative study for the Edmonton Women’sHealth Network (EWHN) of the impact of healthreform on women in the Capital Region foundthat women had five major concerns:

P money is not allocated to appropriate areas ofthe health care system (including health pro-motion and home care);

P financial barriers interfere with women’s abil-ity to care for themselves and their families(in particular for services such as physiother-apy and midwifery);

P minority Canadians have difficulty accessingthe health care system (e.g., because of lan-guage and cultural barriers);

P women sense a lack of trust, understandingand support from health professionals (e.g.,regarding choice of treatment and caregivingresponsibilities); and

P health care reform has had a negative impacton women’s ability to care for themselves andtheir families (e.g., early discharge, stress onhealth professionals) (Bubel and Spitzer,1996).

The concerns expressed by these women includeprovision of services and working conditions forwomen in the system.

In 1997, Thurston, Scott and Crow examined thepublished literature and held three focus groupswith women who represented women’s organiza-tions in rural and urban Alberta to discuss twopolicy initiatives, health reform and funding forwomen’s organizations. The authors concludedthat while substantial work had been done bypolicy-makers on gender-based analysis of social

issues, such analysis was “inconsistent and oftenweak unless the document is specifically about wo-men, and the implications of the analysis cannotoften be found in the policy recommendations thatfollow” (p. 11). The predominant focus of policydocuments that do demonstrate a gender-basedanalysis is on the health needs of women and menidentified by epidemiologic research rather than onthe role of gender in the production of these healthneeds, or the access to and utilization of services.

Thurston, Crow and Scott(1998) surveyed nine ofthe 17 Regional Health Authorities in Alberta todetermine how women’s health was treated inadministrative policies and programs once region-alization occurred. Overall, urban centres had morecomprehensive approaches, and a specific focus onwomen’s health was more evident than in the ruralareas. For example, the Calgary Regional HealthAuthority produced a feminist model recognizingwomen’s lived experiences of health, the influenceof roles, economic resources, societal attitudes,culture, gender and social support on women’shealth. Calgary also made women’s health one ofits top priority areas (Thurston et. al. 1998). Onlyone rural region had a program labelled “women’shealth,” and health services for rural women ap-peared to be limited to reproductive health andbreast cancer issues. However, one re-gion didhave a policy for deal-ing with sexual assaults thatinvolved collaboration between the hospital emer-gency department, police and the local sexual as-sault centre. One needs assessment survey askedfemale respon-dents about programs that wouldinterest them. In sum, despite the hostility of gov-ernment to wo-men’s issues, some Regional HealthAuthorities have paid some attention to women’shealth. This brief overview of Alberta health re-gions showed, however, that woman-centred pro-gramming was narrowly (and medically) defined inmost.


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In 1993, the Edmonton Business and ProfessionalWomen’s Club hosted a talk by health economistRichard Plain who concluded that women losemost when health care services are cut back(Hadley, 1993). Thurston et al. (1998) noted thatit is through such women’s organizations thatwomen have participated in the public policyprocess. Cutbacks to organizations that serve dis-advantaged women have coincided with cutbacksin health services. These cutbacks have re-sultedin a shift in roles of women’s organizations awayfrom advocacy and lobbying so that direct ser-vicedemands can be addressed. Thurston et al. (1998)state that “with inadequate resources to devote topublic policy development, women’sorganizations and thus women, have become dis-connected from the policy process” (p. 17). Thus,mechanisms for parti-cipation in policy develop-ment are being eroded at the same time that wo-men are being required to assume increased bur-dens both as formal and informal caregivers.Despite this, women have organized and beeneffective on many fronts, most often at the locallevel (e.g., providing and sustaining services toabused women, affecting municipal policies andRegional Health Authority programs).

THE EVOLUTION OF ALBERTAHEALTH AND SOCIAL POLICYIN THE CANADIAN CONTEXT

The purpose of this section is to describe selectedaspects of Alberta’s history of health policy de-velopment. It is beyond the scope of this paper tofully explore the socio-political context; how-ever, an overview is important to understandingAlberta’s health system reform. Since provisionsof the British North American Act give provincesprincipal power over the organization of healthand social services, the Canadian health system isactually comprised of several sub-systems. Notsurprisingly, the history of commitment to uni-

versal health care policies has ebbed and flowedwith provincial political and economic tides. Al-though Alberta has been ruled by various conser-vatively-oriented political parties for over 75 years,we have seen variations in health policy there aswell.

In Alberta, Ralph Klein’s Progressive ConservativeParty has been in power since 1992, and it was pre-ceded by two Conservative governments (1971-1985 and 1985-1992) under different leaders (seeAppendix A; Marsh, 2000). Alberta is one of thewealthiest provinces in Canada, has no provincialsales tax and one of the lowest rates of personal in-come tax. Alberta’s wealth is largely dependent onthe oil and gas industry, and although economicdiversification has occurred, this industry contin-ues to hold enormous political influence. As wewill show, the energy sector is strongly in favour ofa market-oriented economy, small government, andis a male-dominated employment sector. The en-ergy sector and its Al-berta political supportershave a history of anti-federalist sentiment, supportglobalization and have the resources to influencepolicy that few civic society organizations couldimagine.

The political influence of the energy sector, notsurprisingly, extends beyond Alberta. The EnergyCouncil of Canada (2000a) says:

The energy sector is an important part of Cana-da’s economy in terms of investment, trade, in-come generation, and employment. The energysector employs more than 280,000 Canadians andaccounts for 6.8 per cent of GDP and 16 per centof total investment in Canada. However, there aremarked regional differences in energy productionand consumption.

As in health, control of the energy sector is sharedbetween federal and provincial governments. TheNational Energy Policy enacted by the federal Lib-erals in the 1970s infuriated the Alberta Conser-


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vatives and became a popular, as well as govern-mental, example of how federal government in-tervention was bad for Albertans. Not surprising-ly, the energy sector was strongly in favour of theCanada-US Free Trade Agreement and NorthAmerican Free Trade Agreement (Cameron andGonäs, 1999). Removal of government controland restrictions is viewed by the energy sector asgood all round:

It is increasingly held that deregulation and theintroduction of competition can result in lowerprices for consumers, stimulate technologicalinnovation, allow the size of government to bereduced, enhance efficiency, and improve thequality of service [emphasis added] (EnergyCouncil of Canada, 2000b).

The overlap in the discourse of health reform—reduced government, efficiency and quality—isnot accidental. It represents strongly held beliefsin the value of a “market-oriented” world. While“Canada’s federal energy policy underwent a ma-jor reform during the mid-1980s, the result ofwhich was a more market-oriented energy sector”(Energy Council of Canada, 2000b), “other gov-ernment agencies” are under scrutiny:

Canadian experience on energy regulation re-flects a broad, growing, and persistent world-wide trend toward the deregulation of monop-oly industries and government agencies. It isincreasingly held that deregulation and the in-troduction of competition can result in lowerprices for consumers, stimulate technologicalinnovation, allow the size of government to bereduced, enhance efficiency, and improve thequality of service (Energy Council of Canada,2000b).

Thus, Alberta has a particular policy history sup-ported by a private sector with a clear agenda, andinternational influence. This sector is domi-natedby males at all levels, which is to say that insiderinfluence by women on corporate culture and

beliefs has been minimal.

The market-oriented approach to health care is his-torical in Alberta. When the economic depressionof the 1930s forced Canadians to re-evaluate thesocial organization of the country, the SocialCredit Party of Alberta advanced an entrepreneur-ial-philanthropic approach to social programs (Cri-chton, Hsu, and Tsang, 1990). The approach wasbased on individual enterprise and responsibilityand was associated with the proliferation of volu-ntary social service agencies and charity hospitals.Municipal assistance programs frequently support-ed the philanthropic enterprises and in some ins-tances, where the economic base for charity did notexist, smaller municipalities became the social as-sistance authority. We continue to see individualenterprise and responsibility in today’s discourse.

In Alberta, the lack of ideological support for so-cial welfare programs meant that as the economyimproved during the 1950s and 1960s, support foran entrepreneurial system began to re-emerge as adominant theme. Medical care prepaymentschemes and fee-for-service options regained via-bility in more economically prosperous times. TheMedical Care Insurance Act was passed in Canadain 1966 despite opposition from the governmentsof Alberta and Quebec. These provinces expressedthe concern that the Act would interfere with prov-incial priorities (Wilson, 1995). The Act promised50/50 federal-provincial cost-sharing of hospitaland physician services if provincial plans met fourhealth care principles (comprehensiveness, univer-sality, pubic administration and portability). The1984 Canada Health Act added a fifth principle—accessibility—thus prohibiting extra-billing anduser fees. Enforcement of the Canada Health Acttook the form of financial penalties levied on thoseprovinces that failed to comply with the Act. Since1984, the federal government has continued to cutback the block transfers to the provinces. BillsC-69 (1990) and C-70 (1991) effectively frozetransfer payments for five years. In 1995, the


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Canada Health and Social Transfer Act (BillC-76), combined federal-provincial health andsocial transfers into one block payment (Wilson,1995). This Act continued the trend toward redu-ced levels of federal expenditures on health carewhile giving the provinces even greater flexibi-lity in implementing health and social programs.The Alberta Government’s response to Bill C-76has been to implement a series of policy initia-tives that reflect a return to an emphasis on indi-vidual enterprise and individual and private res-ponsibility. Specific Alberta policy initiatives willbe explored in Part 3 of this report.

Since the 1930s, Canadians have seen their healthsystems shift from idiosyncratic programs basedon private financing, administration and deliveryto a system unified by principles of com-prehensiveness, universality, public administra-tion, portability and accessibility. The health sys-tem in each province and territory developed dis-tinctive features, but there was a sense, howeverinaccurate, that there was a Canadian system.During the 1980s and 1990s, the unifying natureof the health system was eroded by changes infinancial and administrative mecha-nisms. Rapidhealth reform, rationalization, re-engineering be-came the norm. In 1994, Alberta chose a re-gionalized management system in which 17 re-gional health authorities replaced numerous hos-pital, public health and other boards and com-mittees. As was the intent, these authorities arestrongly influenced by local socio-political con-texts; therefore, a more disparate management anddelivery systems is evident in Alberta. At thesame time, the government department of healthwas reduced in size.

While financial considerations have been identi-fied as the main impetus for regionalizationinitiatives in Alberta, these financial imperativeshave also been couched in discourse around localcontrol, de-institutionalization and community—giving people control over health and health care

decisions, recognizing the public as a partner in thehealth care system, and putting the “consumer”1 atthe centre of decision-making (Alberta HealthPlanning Secretariat, 1993; Alberta Health, 1991;Premier’s Commission on Future Health Care forAlbertans, 1989). This discourse is, of course, fam-iliar to proponents of a more humane health caresystem, and of a system more involved in the pro-motion of health and well-being. What is absent ingovernment discourse, and openly resisted, is ananalysis of the gendered impact of such reforms.

Alberta has a strong history in disease prevention,health promotion, and population health. For ex-ample, the Federal/Provincial/Territorial AdvisoryCommittee on Population Health that was chairedby Cecilia Lorde, Assistant Deputy Minister ofHealth for Alberta, produced an influential popula-tion health report in 1994 (Federal/Provincial/Territorial Advisory Com-mittee on PopulationHealth, 1994). There is, however, a danger of mak-ing the economic goals of health reform those ofprevention and health promotion. As Noseworthy(1999) points out, disease prevention programscould be framed as a reason to reduce health carespending. Unfortunately, Alberta’s expertise at theprogram level in delivering a cross-section ofhealth promotion programs has not included atten-tion to gender as a determinant of health. In a re-view of health promotion projects, none were iden-tified that included this determinant (Thurston,Wilson, Felix, MacKean, Wright, 1999).2

In the face of a provincial budget surplus, the Al-berta Government has begun to discuss reinvestingin health care. For example, discussions have in-

1During the 1990s, the term “consumer” has been increasinglyused in the literature to refer to people who access health ser-vices. The term embodies the market model of health care and thenotion that health care and the social relations of health care arecommodities (i.e., products rather than services).2This included a substantial but not complete sample of Albertaprogram reports.


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cluded the possibility of increasing front-linenursing staff in both hospital and community set-tings and introducing legislation that would ex-pand opportunities for private, for-profit healthcare facilities. Discussions of increasing the rolefor private facilities have, however, been limitedto exploring for-profit options and have neglectedthe role of the private, not-for profit sector. Thenot-for profit sector (e.g., community health cen-tres) has historically played a role in the provisionof health services in Alberta but under strictpublic regulations that limit profits.

Public control of the financial arrangements re-lated to health care is discussed by Donaldson andGerard (1993). These authors suggest that by con-trolling health care finances, governments are per-mitted more direction of the health care system“in the pursuit of societal objectives” (Donaldsonand Gerard, 1993, p. 53). Discussions relating tohealth care reform and privatization initiatives inAlberta have included debate about the relativeweight that specific policy initiatives give to ob-jectives such as efficiency and equity. In econo-mics, maximizing the efficiency of the system orprogram means maximizing social benefits withscarce resources (Mooney and Sal-mond, 1994). Itrelates to whether a program is worth doing (allo-cative efficiency) and the best ways of producingworthwhile programs (operational efficiency).Equity refers to both financial equity and equityof opportunity to access services.

Although there is currently a budget surplus inAlberta, there are not infinite dollars available tofinance the health care system. In a climate oflimited resources, the interaction between equityand efficiency implies a trade-off. That is, if thereare scarce resources, financial equity and equityof access may be ensured if efficiencies arecompromised. In Alberta, health reform has madea number of trade-offs; for example, provision ofservices in remote and in rural areas maycompromise the objective of finding the “bestways” to produce worthwhile programs (i.e., oper-

ational efficiency). Legislation that is currentlybeing introduced by the provincial government(Bill 11) is purported to increase efficiencies in thesystem (i.e., decrease waiting lists). While thereare questions about whether such efficiencieswould be found through this legislation, there arealso concerns that potential increases in efficiencywould be at the expense of both financial equityand equity of access. Bill 11 would allow privatesurgical facilities to operate using both public andprivate financing; therefore, in such institutions,the provincial government would be permitted lesscontrol over the objectives that guide service provi-sion. By giving up control, the government mightnot be able to ensure a balance between equity andefficiency.

Private health providers bring many factors fromthe market sector into play in the health system.Taft and Steward (2000) point out that for-profitcompanies have added costs such as taxes, market-ing, payments to investors, and duplication of ex-pensive equipment among competing providers.Conflicts of interest arise when private providersare also in decision-making positions within thepublic health care system. Several examples of thishave been noted within one of the largest AlbertaRegional Health Authorities—in Calgary.3 Private

3Dr. Chen Fong was head of radiology at Foothills Hospital inCalgary at the same time as he was medical director for WesternCanada MRI, and is now head of radiology at the CalgaryRegional Health Authority (CRHA). When an MRI unit wastaken out of operation during a move between hospitals, theCRHA referred urgent MRI cases to Western Canada MRI. Dr.Kabir Javraj, an owner of Surgical Centres Inc., was hired by theCRHA as their chief medical officer six weeks after his companywas awarded an acute-care services contract. In 1998,opthamologist Dr. Peter Huang and otolaryngologist Dr. IanHuang, owners of Enterprise Universal Inc., purchased the HolyCross Hospital facility (which had been closed by the CRHA) for$4.5 million. At the time, Peter Huang was head of opthamologyfor the CRHA and had a contract to perform all of FoothillsHospital’s cataract surgery in his private clinic. After EnterpriseUniversal Inc. purchased the Holy Cross Hospital, it wasawarded a contract to perform eye, nose and throat, and footoperations at the Holy Cross site.


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interests also conflict with public goals, such as aprovincial breast screening program. Private ra-diologists fear loss of a profitable population ofclients if the Alberta Cancer Board is permitted toinstitute such a program. These radiologists maybelieve strongly in the benefits of a systema-ticscreening program, follow-up, and research, buttheir business models demand that they be able toscreen any woman who requests screen-ing,regardless of practice guidelines, and that theymaintain control of the case through records.

The private provision of health services in Albertahas existed for a number of years. Therefore, theargument that there is no room for privateenterprise within the Alberta health care systemwill persuade few Albertans. Physicians andphysiotherapists, for example, may be salariedemployees within the public health system,private practitioners who work under contract toRegional Health Authorities, or who directly billAlberta Health and Wellness for the services thatthey provide. In each of these situations, the pro-vider may be working privately, but her or his ser-vices have been financed publicly. This single-payer system is a tax-based public insurance sys-tem that pays for health services that are mainlysupplied by the private sector (Fuller, 1998). Asdiscussed below, it is the expansion of privatefinancing mechanisms (e.g., an individual payingdirectly for uninsured or enhanced health careservices or paying for private insurance policies inaddition to the public premiums) that threatens toundermine the principle of accessibility.

Donaldson and Gerard (1993) present an eco-nomic model of the public-private mix in the fina-ncing and organization of health care that can beused as a starting point in assessing privatizationinitiatives. This model illustrates four possiblescenarios for financing and providing health care(Figure 1). That is, public financing with eitherpublic provision (1) or private provision (2) andprivate financing with either public provision (3)or private provision (4). Currently, the healthsystem in Alberta is dominated by scenarios (1)

and (2). There are instances, however, where en-hanced services have been offered by either public(3) or private providers (4) (e.g., the provision of ahigher quality lens for eye surgery). The latter twoscenarios have the potential to compromise fin-ancial equity and equity of opportunity to accessservices, and reflect the emergence of a second tierof health care in which those who can pay willreceive a higher quality service or more rapid ac-cess to service than those who are unable to pay(Donaldson and Schiell, 2000).

PUBLIC/PRIVATE MIX IN HEALTH CAREFINANCING AND PROVISION

PROVISION

Public (1) Private

FINANCE

(2)

Private (3)(4)

(1) Public finance & public provision (2) Public finance & private provision (3) Private finance & public provision (4) Private finance & private provision

Source: Donaldson, C. and Gerard, K. (1993). Economics ofHealth Care Financing: The Visible Hand. London, UK: Mac-Millan. p. 53.

Part of the discourse around efficiency involvesimplying that public employees as greedy, inef-ficient, and even lazy. Jerome-Forget and Forget(1998) and McArthur, Ramsay and Walker (1996)state that health care wages have been rising fasterthan the industrial average. Jerome-Forget and For-get also suggest that hospital workers are less pro-ductive (from 1969 to 1989) than those from othersectors based on the number of patients treated perhour of work. They also cite a U.S. study (cf.


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Ashby and Altman, 1992) that found productivityincreases to be small despite increased labour costinputs for similar levels of case complexity overtime, with little added bene-fit to patient well-being. McArthur et al. (1996) compare many ofthe unionized jobs in hospitals (excluding nurses,technicians and lab assistants) with those of un-ionized hotel workers as evidence that public sec-tor health care workers are overpaid relative totheir private sector counterparts. People who workin hospitals, however, are at greater risk of expo-sure to germs, sometimes need to provide non-clinical assistance to patients, such as helpingthem to use phones or call for a nurse (Armstrongand Armstrong, 1996), and serve a population thatis generally much more stressed than in the hotelindustry.

When it comes to professionals, what is absentfrom the analyses of labour costs is the context ofhistorically low pay and status of nurses prior tothe 1970s (Armstrong and Armstrong, 1996) andthe lengthy struggle for better pay and workingconditions. This raises the question of whether theabove-average wage gains of hospital workers(many of whom are nurses) was simply a “catchup” from being undervalued and underpaid in ear-lier times. As noted by Renouf (1995), health carewages in Alberta did rise faster than both averageincomes and inflation during the 1980s; however,these increases addressed prior pay inequities:

These gains did not come without struggle,exemplified by province-wide strikes of union-ized nurses in 1980, 1982, and 1988. Healthcare unions fought to increase pay levels which,in real terms, had been very low for theirpredominantly female membership. Com-pensation increases in the 1980’s were neitherunjustified nor the product of a lax andfree-spending provincial government. Primarily,they reflected pressures to address long-standing pay inequities (p. 229).

The government actively opposed the wageadjustments that occurred (Renouf, 1995).

PUBLIC PARTICIPATIONThe government’s commitment to privatization ofthe health system has also been accompanied by atrend toward increasingly limited and controlledpublic participation in the planning processes.Alberta Health has held various types of com-munity consultations (e.g., the Rainbow Report in1989, Partners in Health in 1991, Roundtables in1993, the Health Summit in 1999). In addition, theAlberta Advisory Council on Women’s Issues helda public consultation process in 1996 and theProvincial Health Council of Alberta held publicconsultations in 1997.

Although these avenues provided opportunities forinput and feedback to decision makers, it is notclear how the data gathered was translated into pol-icy decisions by Alberta Health and the health re-gions. While the early consultations associatedwith the Rainbow and Partners in Health Reports(see Part 2 of this paper) appeared to be open andresponsive to the concerns of the public, more re-cent consultations have appeared much less res-ponsive. For example, an Edmonton Journalcolumnist who covered the 1993 Roundtablesreported that one of the co-chairs was to sum-marize the discussions from both the public andinvitation-only consultations, but there was no in-formation on how he would decide on the mainthemes or handle conflicting views, suggesting thatnot all perspectives were given equal respect:

In the roundtables you had to listen carefully topick out the whiners and special interests. Thevoice of Alberta was a lot like crude oil. Before itcould be used, it had to be purified (Lisac, 1995,p. 156).

In contrast, the Provincial Health Council con-sultations reported diverse feedback about thehealth care system, both positive and negative. Forexample, public meetings and focus groupsreflected concerns that health reform has focussedtoo much on cost control rather than quality; thatthere has been little citizen involvement in the


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decision-making of their Regional HealthAuthorities; and that providers are not always sen-sitive to patient needs. They also supported anemphasis on prevention and encouraged more at-tention to this area. In addition to these face-to-face meetings with members of the general public,the Council also visited health authorities, inter-viewed former board members about their ex-periences with health reform to date, and con-ducted a province-wide survey of Albertans. Fromthese various types of consultation, the Councilconcluded that:

...cost containment through government expen-diture has largely been achieved, although therehas been an increase in cost to individuals, em-ployers and communities (Provincial HealthCouncil of Alberta, 1997a, p. 17).

On a more positive note, the Council also foundmore recognition of the linkages among lifestylechoices, social and economic policy, and betterhealth. The Council emphasized integration ofhealth and other sectors was needed to movehealth reform forward, as well as better use ofprovider skills and health facilities, and betterprevention programs. This example illustrateshow public and other forms of consultation by agovernment body can be used to provide bothpositive and critical feedback on policy and makeconstructive suggestions for change. In 1997, theCouncil was examining ways to further expand itsprocess for consulting with Albertans, particularlyAboriginal people. The Council was eliminated in1998.

Shortly before its demise, the Alberta AdvisoryCouncil on Women’s Issues (AACWI) carried outa public consultation process with women acrossAlberta. This consisted primarily of focus groupsof women from diverse backgrounds, as well asopportunities for written or telephone submis-sions. In their discussions of their attempts tocommunicate with the government, most who par-ticipated felt their efforts had minimal results interms of effecting change. When discussing bar-riers to effecting change and having impact,

women identified lack of awareness of women’sissues (including on the part government); fear ofconsequences in their communities for speakingout; a belief that the government does not listen,especially to women; as well as more practical bar-riers like lack of time, money, knowledge and com-fort with speaking up (Alberta Advisory Councilon Women’s Issues, 1996b).

Though a minority of women favoured discon-tinuing AACWI, many believed its closure “wouldweaken the government’s ability to create legis-lation, regulation and policy that were sensitive towomen’s needs and concerns.” (Alberta AdvisoryCouncil on Women’s Issues, 1996b, p. 28). Mosteither supported continuing AACWI or developinga replacement structure that would still provide op-portunities for women to work with government.Of all the options that were put forward, the gover-nment chose to follow through with its intent toclose AACWI. While women’s organizations havestruggled to provide services where governmentcutbacks created gaps, their ability to engage inconsultation at the provincial and local levels hasbeen restricted. In addition, given the anti-feministstance of the current government, there is littletrust that women will even be listened to, let aloneheard.

Health care was the most frequently raised majorconcern in the AACWI consultations. Specificconcerns relevant to the present discussion ofprivatization included:

P impact of cuts on quality and availability ofmedical treatment;

P concern about increased use of users fees andpotential for limited access to adequate healthcare by poor women and their families;

P concern regarding government and communityexpectations that women will be long-term care-givers at home for family members;

P concern about skill levels and quality of train-ing for home care staff and other out-of-hospitalcare providers; and


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P future availability of abortions given recentdiscussions regarding de-insuring abortionsfrom health care coverage (the governmentdecided not to de-list abortions from healthinsurance coverage, and covers full costs ofabortions performed in private clinics as wellas hospitals). (Alberta Advisory Council onWomen’s Issues, 1996b)

The use of progressive discourse to mask regres-sive policy directions is evident in policy relatedto social policy initiatives in Alberta. For exam-ple, Kline (1997), in discussing the Action Planfor the decentralization of children’s services toregions (prior to its implementation), describeshow the government uses the discourse of com-munity to promote private responsibility forchildren’s needs (in the family and done primarilyby women), rather than collective community re-sponsibility. Kline (1997) notes that early inter-vention is presented as an individual issue ofskills training for parents, and social issues suchas “low income” and “family violence” are seenas family and community issues that are not theresponsibility of government. Thus, there is no re-cognition of the relationship between social andeconomic inequalities and individual actions.Kline (1997)also points out that:

P groups designated to be represented on the Re-gional Health Authorities include categoriessuch as parents, volunteer organizations,religious groups, elders and service clubs—with no mention of women or gender;

P the shift to more community involvement canbe used not only to recognize skills of com-munity members, but also to justify de-profes-sionalizing of work (and fewer social workers,who are mostly women);

P the process of contracting-out may not actual-ly facilitate meaningful involvement of com-munity agencies as contracts may go to for-profit businesses or large chains, and grass-roots agencies could be co-opted by govern-ment funding to provide services on the gov-ernment’s terms (e.g., restrictions on lob-bying);

P the Action Plan talks about more power andcontrol for First Nations communities, but inreality they will be constrained by governmentrequirements and that the language of the planactually “pathologizes” First Nationscommunities.

Kline (1997) does not view the formation of re-gional authorities as actually giving more powerand control to local communities. She notes thatsuch structures actually insulate the governmentof accountability, and also observes that in Mani-toba and Ontario local decision-making structureswere disbanded when they became critical of gov-ernment policy and demanded change, includingmore funding and expanded services. This is apattern that has been repeated in Alberta with thedisbanding of the Alberta Advisory Council onWomen’s Issues, the Provincial Health Counciland decreased funding for women’s organiza-tions. The AACWI consultation (1996b) contain-ed several recommendations to ensure representa-tion of women in government decision making.These included:

P gender analysis of legislation, policies andprograms;

P improved communication through an annualconsultative forum for women and women’sgroups;

P increased communication by MLAs withwomen and women’s groups in their constitu-encies;

P political party support for women seeking andattaining office and more gender balance ingovernment appointments;

P support (including funding) for independentlyconducted policy research addressing issues ofconcern to women; and

P inclusion in business plans and performancereports of differential impacts of legislation,policies, programs and other decisions onwomen and men, including sex-disaggregateddata (AACWI, 1996b).


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Strategies such as these must be set in place toensure that policy is responsive to the needs ofwomen.

Given the government’s lack of responsiveness topublic input, it is not surprising that there appearsto be a great deal of skepticism among Albertansregarding their ability to influence the policyprocess. This is apparent in recent discussions

around the introduction of Bill 11. The provincialgovernment has not held any open debates aboutthe legislation, but it did (briefly) propose todisperse “truth squads” to inform Albertans aboutthe implications of the Bill. At the same time,fora sponsored by other organizations and groups(e.g., the CBC, Friends of Medicare) have beenwell-attended by participants vocal in theiropposition.

PART

2PRIVATIZATION OF HEALTH CAREIN ALBERTA

THE CURRENT VISION FORTHE HEALTH OF ALBERTANS

The provincial government’s vision for the healthof Albertans has evolved over the years and, inthe course of this evolution, has facilitated thecurrent shift toward policies that emphasize great-er private responsibility for health care. While thelanguage of privatization has become more exp-licit, the gendered implications of this shift re-main absent from the discussions of health carereform.

The following information, taken from the“Health 1999-2002 Business Plan” section ofBudget 99: The Right Balance: Fiscal and Busi-ness Plan Documents (Alberta Treasury, 1999),presents some the Alberta Government’s currentcommunications about the health care system.

In the 1999-2002 business plan from AlbertaHealth (the name of the Ministry changed from“Alberta Health” to “Alberta Health and Well-ness” in the Spring of 1999), the three major dim-ensions of emphasis were access to quality healthcare services, promoting and protecting the healthof individuals, and the contribution to health ofhealthy social, economic and physical environ-ments (Alberta Treasury, 1999). This same busi-ness plan also states three “system characteris-tics” of relevance to this discussion ofprivatization (p.2):

P Alberta will continue to be part of a publicly-administered health system that guaranteesuniversal access to medically-necessary hos-pital and medical services without user fees orextra billing;

P the Alberta health system will continue to pro-vide benefits in excess of the Canada HealthAct; and

P incremental introduction of better approachesto health care will occur as evidence demon-strates their outcomes.

This plan opens the door for privatization throughoptions for the provision of “benefits in excess”and “better approaches.” The present 2000-2003business plan, while emphasizing consistency tothe principles of the Canada Health Act, is ex-plicit about the private sector as a partner:

The achievement of this vision requires indi-viduals to take responsibility for their health intheir communities, in collaboration not onlywith the Ministry and providers of health ser-vices, but with a wide variety of parties in-cluding other Ministries, other levels of govern-ment and the private sector (Alberta Treasury,2000a, p. 3).

This statement, with its reference to individualscollaborating with the private sector (amongothers), did not appear in the previous plan of1999/2002. The timing of adding a statementabout collaboration that includes individuals


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collaborating with the private sector—in the yearthat Bill 11 is being introduced—suggests thegovernment’s intention to allow expansion of theprivate sector, including the ability of privateclinics to market non-insured services to Alber-tans. On the other hand, the statement could beread to mean that people should take a more ac-tive role in their insured health care treatment thatis provided by physicians (who are publicly-funded private providers), or joining privatephysical activity programs. The statement—though more specific in mentioning the privatesector than last year’s plan—allows for manyinterpretations about both the role of the privatesector and the nature of collaboration. Thoughpolicy documents such as departmental businessplans usually are written in broad terms, furtherdefinition at the operational level is needed todefine the intended roles for the private sector inAlberta’s health care system.

THE PROVINCIAL PLATFORM:KEY POLICY INITIATIVES

The current emphasis on private responsibility forhealth care has been a consistent theme in theAlberta health system since the 1930s. For a briefperiod during the 1980s the force of this under-lying ideology was diminished and policies thatreflected the objective of equity were able toemerge (e.g., the legislation that enabled thecreation of the Alberta Advisory Council on Wo-men’s Issues). In the late 1980s, there was again ashift back to a focus on individual responsibilityfor health. This emphasis has continued to deve-lop in policy documents throughout the 1990s.

In this section, we use a gendered lens to examinea number of key policy documents that reflect thisemphasis on private responsibility for health care.While documents that were generated during theearly stages of health reform in Alberta do reflectan understanding of the need to clarify the rolesof individuals, organizations and sectors in thehealth care system, this does not evolve into aunderstanding of the differential impact of suchroles for men and women.

1. The Rainbow Report

In December 1987, the Premier of Alberta, DonGetty, signed an Order-in-Council establishingthe Premier’s Commission on Future Health Carefor Albertans. The purpose of the Commissionwas to conduct an inquiry on the future healthrequirements for Albertans with respect to fourgeneral Terms of Reference (Premier’s Com-mission on Future Health Care for Albertans,1989, p. 12):

P to examine changes in future health require-ments as they relate to population trends, ad-vances in active treatment and preventativehealth measures, health training and tech-nology, types and patterns of illness, publicneeds and expectations, organization fundingstructures, and such other factors that may berelevant;

P to examine roles, responsibilities andexpectations of individual Albertans, volun-teers, community agencies, the medical andrelated health care professions, private sectorinterests, and governments in planning,delivering and funding future health servicesand programs;

P to examine incentives and mechanisms tomaintain quality and accessibility of healthservices; to encourage the most innovative,effective and economical use of healthresources and to focus on the promotion ofhealth and the prevention of disease; and

P to examine, comment on, and make recom-mendations on such other matters that theCommission may deem to be relevant.

This mandate clearly indicates a recognition ofthe need to maintain quality and accessibility ofhealth services while clarifying the roles of thepublic and private sectors in health care deliveryand funding, including the roles of individualsand community agencies.

Chaired by Lou Hyndman, the eight-memberCommission was comprised of three women andfive men, and had two years to complete its task.Throughout 1988, the Commission implemented


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extensive methods to gather information relevantto its task, including town hall meetings, publichearings interviews, written submissions, andtoll-free telephone submissions. By July 1989,1,600 written and telephone submissions hadbeen received. The data were qualitatively andquantitatively analyzed and additional infor-mation was gathered on a number of the majorconcerns and issues. In early 1989, a NewsletterSpecial Edition which summarized the findingsfrom each of the town hall meetings and publichearings was circulated to the public for furtherfeedback (Premier’s Commission on FutureHealth Care for Albertans, 1989b). The RainbowReport: Our Vision for Health contained 21 majorrecommendations which distilled down to the fol-lowing six directions for change in the Albertahealth care system:

1. “Healthy Albertans, living in a healthy Al-berta” can be achieved if the government isprepared to be bold....We need legislation—including a strictly-enforced Alberta Code ofHealth and Environmental Ethics—that en-sures that the health of individual Albertans isconsciously and publicly in balance witheconomic development and other initiatives.

2. More individual responsibility forhealth—1% of the total Alberta Healthbudget needs to be allocated to targetedpromotion and prevention programs.

3. Return the authority for decisions affectingthe relevance of health services to peoplewithin the communities familiar with localneeds and priorities. Health authorities, withresponsibility for allocating funds and com-prised of locally-elected trustees, should beestablished throughout the province.

4. Individual Albertans and/or their designates,should have the responsibility for disbursingand managing the funds required for theirhealth and health care needs.

5. The Government of Alberta should providematching grant funds for the establishment ofa publicly-accessible Ethics Centre to assistAlbertans facing complex issues which re-quire deliberation and discussion (e.g., dyingwith dignity).

6. The vision of “Healthy Albertans, living in ahealthy Alberta” needs an Advocate whowould communicate with and to Albertansand the government about health and healthcare.

In the years since its publication, The RainbowReport has been heralded as the foundation formany of the current reforms. In reality, few of therecommendations have been implemented asenvisioned. Although the province has movedtoward a regionalized health system (17 regionsrather than the recommended 9), the RegionalHealth Authority boards remain appointed, notelected. The Provincial Health Ethics Networkhas been established. The vision, referred to inthe sixth direction for change remained the visionfor Alberta Health until this year when it waschanged to “citizens of a healthy Alberta achieveoptimal health and well-being” (Alberta Treasury,2000a, p.3).

Despite the Commission’s strong emphasis on thedevelopment of a health system based upon acommon vision and values, there has not beenexplicit discussion of the values underlying thevision. The vision proposed in The RainbowReport is one of understanding of the need tobalance individual rights with the societal goodand for the government to assist, support andprotect individuals in achieving their individualhealth goals (Premier’s Commission on FutureHealth Care for Albertans, 1989a). The centralrole of the government is reflected in the sug-gestion that the provincial government supportindividual responsibility for health by dedicatinga percentage of the budget to health promotionand disease prevention initiatives.


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The Commission highlighted the need for govern-ment to provide special support to some indivi-duals or groups who may face barriers to acces-sing health care services (i.e., young people,women, the elderly, Aboriginal Albertans, andpersons with disabilities). The report links thespecial support required by women to the mul-tiple roles that women play (i.e., “homemakers,parents, breadwinners, career people, care givers”and “maintaining the primary role in decision-making about child health care matters” (Pre-mier’s Commission on Future Health Care forAlbertans, 1989a, Vol. II, p. 52). Thus, while thefinal recommendations are couched in gender-neutral terms, the substance of the report reflectssome level of understanding regarding differentialaccess to health care services for women and meneven though women’s roles were primarily in therealm of caregiving. While an understanding ofthe unique needs of women was reflected in thediscussion of access to services, the same level ofunderstanding was not apparent in the section ofthe report that dealt with health care providers.The thrust of the report in this area was to em-phasize the need for building positive relation-ships among health care providers and betweenhealth professionals and the individuals to whomthey provide care. Strategies were advanced toreduce the barriers among providers and betweenproviders and patients.

In the appendices to The Rainbow Report, theCommission took the opportunity to comment onthe importance of volunteers in the health sector.While the report does identify that six of tenvolunteers are women, having volunteers is seenas a strength of the system. There is no furtheranalysis to examine the impact this level of vol-untarism has on the lives of women, or thechanges occurring in voluntarism and impli-cations for the future. Dependence on unpaidlabour that may not be available as more andmore women enter the labour force could be seenas a weakness of the system.

2. Partners in Health

To assess the findings and recommendations ofThe Rainbow Report, the government of Albertaestablished a Cabinet Task Force. The TaskForce, chaired by the Minister of Health, NancyBetkowski [MacBeth]4 “was to ensure that anyrecommendations accepted and implementedwould support the principles of universality andreasonable access, provide for the continued pro-vision of basic health services, support healthpromotion, take into account environmental andeconomic factors, and not restrict access to healthservices because of an individual’s inability topay” (Alberta Health, 1991, p. 2). In 1991, theTask Force published its response to The Rain-bow Report, entitled Partners in Health: TheGovernment of Alberta’s Response to the Pre-mier’s Commission on Future Health Care forAlbertans (Alberta Health, 1991). The reportexplicitly stated that “The Rainbow Report [was]designed to encourage Albertans to become morefully involved in defining and setting directionsfor the health care system” (p. 3). In keeping withthis commitment to citizen involvement, the TaskForce solicited and analyzed submissions fromindividuals (200) and interest groups (179) fromacross the province. It is not clear from the reporthow the public input was solicited. In the list oforganizations, there are very few that representwomen’s organizations—the Catholic Women’sLeague of Canada and perhaps the Alberta As-sociation of Homemaker Services are the onlytwo such organizations. The Alberta AdvisoryCouncil on Women’s Issues is conspicuouslyabsent from the list. The Task Force supported, tovarying degrees, 17 of the 21 specific recom-mendations arising from The Rainbow Report. Inmany instances, the Task Force supported recom-mendations in principle, but identified the need to

4Ms. MacBeth is currently the leader of the provincial LiberalParty.


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collaborate with other sectors to develop ap-propriate strategies (e.g., education, justice, theenvironment).

The recommendations that were not supported bythe Task Force were the suggestion that the gov-ernment explore allowing all Albertans to managethe funds required for their health care needs, thecreation of a provincial Health Advocate (thiswas felt to be the role of the Minister of Health),and the establishment of Regional HealthAuthorities. The government endorsed the needfor coordination and cooperation on regionalbasis, but not through RHAs. At this point intime, the provincial government still espoused theneed for a strong provincial role in the coordina-tion of the health system. The public responsesargued against RHAs on the grounds that theywould create another level of bureaucracy, reducelocal autonomy, and would have uncertain effectson accountability mechanisms. It is interesting tonote that within three years, the provincial gov-ernment had reversed its opposition to RHAs (seeThe Regional Health Authority Act below).

3. Starting Points

Following the Rainbow Report and the Partnersin Health report, one of the first documents of theKlein government to outline health reformdirections was Starting Points: Recommendationsfor Creating a More Accountable and AffordableHealth System (Alberta Health Planning Sec-retariat, 1993). This report builds on the feedbackthe provincial government obtained through aRoundtable process consisting of public forums,written submissions from the public, visits tohospitals, consultations with health officials inother provinces, and a review of recent past re-ports on health system issues prepared for theAlberta Government. The report was prepared byMLAs Dianne Mirosh and Lyle Oberg, the res-pective Chair and Co-chair of the Public Round-tables on Health.

The report’s first recommendation is that “thenew system adopt a service-oriented attitude thatplaces the needs of the consumer as the highestpriority” (Alberta Health Planning Secretariat,1993, p. 13). This recommendation addressesmaximum access and choice (involving a range ofproviders and locations). One-stop shopping isrecommended, where a person can access therange of providers and options when entering thesystem at any point. The report(Alberta HealthPlanning Secretariat, 1993) assumes not all theseavailable services will be covered by AlbertaHealth Care:

However, consumers will recognize that theywill need to pay for services considerednon-essential [emphasis in original] under anewly created definition of basic health ser-vices (p. 13).

The second recommendation in the report buildson the last point:

It is recommended that a definition of basichealth services [emphasis in original] be es-tablished. This definition will clarify healthneeds and health wants (p. 15).

This recommendation does not necessarily pro-mote privatization, though the intent to “providemaximum value to the consumer” is consistentwith a market perspective. The report uses thelanguage of best practices to say that the resultwill be a definition of basic health services whichensures taxpayers only fund those services thatmeet established standards for quality health, andprovide maximum value to the consumer (long-term benefit) and the taxpayer (cost-effective-ness).

The report does acknowledge that “cost-effec-tive” does not always mean the lowest cost ser-vice, and that occasionally, a more expensiveservice may be required to achieve a better long -term result. The report also states that defining


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basic health services will restrict the number ofpublicly funded services offered, and that the“consumer first” approach demands that con-sumers have access to an optimum number ofnonessential services. It also states that:

We must understand that the consumer’sright to a maximum choice of nonessentialservices will include the consumer responsi-bility of paying for those services [emphasisin original] (Alberta Health PlanningSecretariat, 1993, p. 15).

This statement reflects a free-market approach.Also, choice is made in a context of not only whatis available, but how it is promoted or marketed.Thus “need” can be created—which is a fearexpressed by critics of private clinics that are ableto offer “enhanced” uninsured services. Thisraises the question of who is involved in discus-sions of what is essential and non-essential, andto what extent those involved understand wo-men’s health issues.

A subsequent recommendation is to establish acommission to define essential services. Laterrecommendations on accountability also mentionpayment, as well as individual responsibility forhealthy lifestyles and use of the health care sys-tem and the need to educate consumers about thecosts of health services and how to use them pro-perty (e.g., through issuing receipts to consumersafter they use the health system and/or throughelectronic “Smart Cards”).

A number of other recommendations pertain toregionalization (e.g., board structure, integrationof organizations and services, funding formulas,more focus on wellness, roles of province and re-gion in capital construction). However, some re-commendations are directly pertinent to the cur-rent discussion of private facilities working undercontract to Regional Health Authorities. Onestates:

It is recommended that non-profit associationsand the private sector be given a greater

opportunity to provide facilities. Health re-gions should be encouraged to work withnon-profit associations and the private sectorto establish joint venture or autonomousfacilities. The provision of health services tothe facilities would remain the responsibilityof the region (Alberta Health Planning Secre-tariat, 1993, p. 21).

It is not clear from this statement whether theregion is responsible for delivering the servicesdirectly, or merely paying for the service delivery.In the latter case, the delivery could be by govern-ment, non-profit, or private for-profit providers.The wording of the recommendation does not pre-clude any options.

Later recommendations in the section entitled“Paying for the Health System” are more explicitabout the potential role of the private sector indirect service delivery. In addition to reiteratingthe need for “consumers paying for servicesdeemed to be non-essential,” this section also dis-cusses using the private sector to help reduce un-necessary overhead costs. For example:

The private sector must be allowed to provideservices if the services meet or exceed healthstandards... Partnerships can be createdbetween the private sector and local associa-tions for wellness promotion, contract healthservices, and so on. These partnerships mustbe encouraged wherever possible to offsetsystem costs (Alberta Health Planning Secre-tariat, 1993, p. 26-27).

There is also a recommendation that regionsdevelop long-term partnerships with pharma-ceutical firms to reduce drug costs.

The Starting Points report concludes with a num-ber of challenges and questions which are notrecommendations but are presented as points toconsider. Some of these relate to the potential forvarious forms of privatization (e.g., health regionsselling services to non-Albertans, contracting outfood, laundry and maintenance services, partner-


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ships between public and private sector x-ray/diagnostic labs). This section also raises the issueof shorter hospital stays and more out-patient ser-vices, but does not acknowledge the likelihood ofan increased role for informal caregivers (who aremost often women). Although the five principlesof the Canada Health Act—public administration,comprehensiveness, universality, portability andaccessibility—appear in an appendix, there is noexplicit reference to them in the report’s recom-mendations, and no reference to the appendix inthe body of the report.

4. Health Goals for Alberta

In late 1993, Health Goals for Alberta: ProgressReport (Alberta Health, 1993) also mentions linksto the private sector. In a discussion of main-taining quality and accessibility of the health caresystem, this document states:

Partnerships between those who provideservices, those who use health services andthose who pay for health services, will beneeded. Only in this way can we allocate ourresources for the greatest benefits of all Al-bertans (p. 12).

Partnerships are also recognized as one of the sixprinciples that are part of the vision “Healthy Al-bertans living in a healthy Alberta” (AlbertaHealth, 1993):

Individual Albertans and people representingorganizations from inside and outside theformal health system need to be involved inrealizing our vision for health (p. 17).

These statements are not specific about who thepotential partners are. The very general wordingof the document could include many meanings of“partnership.” If partnership is intended to in-volve patients and their families in moremeaningful ways as they deal with the health sys-tem, it would not be inconsistent with woman-centred models of care (see Horne et al., 1999 for

examples.) If partnership, however, means in-formal caregivers being expected to take on moreresponsibilities as health care staff are cut or topay a greater share of their health care costs, thenpartnership would be more akin to cost shifting.

Later in the document, Goal 4 addresses healthservice delivery, and lays some early groundworkfor the approach to health care reform that fol-lowed when health regions were developed. Thisgoal addresses when and where services are pro-vided, by whom, how they are integrated to im-prove accessibility, and cost-effectiveness. Thereport suggests the need for new ways ofdelivering services focussing on the individualconsumer and the particular needs of each com-munity, and suggests strategies to support peoplewith health limitations to remain in their ownhomes, partnerships with groups outside the tradi-tional health system and cost-effective servicedelivery.

5. The Regional HealthAuthorities Act

In 1993, despite earlier indications that RegionalHealth Authorities were not favoured by the gov-ernment (Alberta Health, 1991), the concept re-emerged as a strategy to facilitate the coordina-tion of responsive services. Based on the Pro-vincial Roundtables on Health held in Septemberand October 1993, the Health Planning Secre-tariat recommended that “a regional structure becreated for local decision-making” (AlbertaHealth Planning Secretariat, 1993, p. 17). The Health Planning Secretariat endorsed thisconcept because the members felt it would:

P encourage local accountability for providingaffordable health services;

P recognize that health needs vary from regionto region and give providers and consumersthe freedom and flexibility to customizedelivery to meet those needs;


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P streamline the health system by eliminatingnearly 200 boards;

P provide potential economies of scale;P encourage institutional and professional co-

operation within and between regions; andP encourage innovation within and between

regions.

The language used to describe the anticipatedimpacts of regionalization is clearly the languageof efficiency (e.g., “accountability,” “customizedelivery,” “streamline,” “economies of scale”),with little emphasis on equity. While membersthe Secretariat endorsed regionalization for thesereasons, it is unclear that mechanisms were set inplace to ensure that these outcomes could beachieved. Regional Health Authorities were not,for example, supported by mechanisms to assistwith accountability (i.e., a health informationsystem). The lack of accountability was em-phasized in the 1998-1999 Annual report of theAuditor General of Alberta in which he reiteratedhis recommendation from previous years that theDepartment of Health work with health authori-ties to improve the accountability system (Valen-tine, 1999). One proposed mechanism for cus-tomizing delivery was to mandate the creation ofCommunity Health Councils in each RHA. How-ever, their formation has been inconsistent acrossthe province, and there are no specific guidelinesfor diversity of representation within the Com-munity Health Council regulations (Governmentof Alberta, 1997). To this point, women have nothad much success in customizing the healthsystem to meet their needs. Increased numbers offemale medical graduates have helped (e.g.,women tend to choose female physicians) but ofthe leaders in medical education and medical re-search, only 20% are women even though medi-cal classes are 50% female. In addition, thesewomen tend to be in the lower ranks of academia(McKenna, Hanion-Dearman and Yassi, 1999).

It is interesting to note that between 1991 and1993, the government had completely reversed its

interpretation of some of the potential impacts ofregionalization. In the Partners in Health report(Alberta Health, 1991) some of the reasons forrejecting the concept of regionalization includedthe uncertain impact on accountability, addedbureaucracy, and the impression that improvedcoordination of health services was not neces-sarily linked to “boundary lines on a map” (p.40).

The Regional Health Authorities Act(Government of Alberta, 1994) legislated the for-mation of 17 Regional Health Authorities andtheir links with two existing boards (the MentalHealth Board and the Alberta Cancer Board). The17 regions replaced over 200 separate boards ofhospitals, health units and other health serviceinstitutions. Initially, RHA boards were appointedwith the provision within the Act for havinglocally elected Boards, this has yet to happen.The Act legislates that the RHAs shall:

P promote and protect the health of the pop-ulation in the health region and work towardsthe prevention of disease and injury;

P assess on an ongoing basis the health needs ofthe health region;

P determine priorities in the provision of healthservices in the health region and allocatehealth resources accordingly;

P ensure that reasonable access to quality healthservices is provided in and through the healthregion; and

P promote the provision of health services in amanner that is responsive to individuals andcommunities and supports the integration ofservices and facilities in the health region.

The interpretation of this legislation has variedfrom one Regional Health Authority to anotherand is easily influenced by the socio-politicalcontext within the region, such as differences inrates of eye surgeries (see Armstrong, 2000).

Five years after the implementation of region-alized health management in Alberta, the assump-


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tions of its benefits have yet to be demonstrated.Donna Wilson (2000a) questions whether region-alization is “a successful format for managinghealth care planning and delivery of health ser-vices in Alberta” (p. 2) and highlights severalfeatures of regionalization that have added to thecost of managing the health system. Wilson con-ducted a basic cost-benefit analysis of health sys-tem performance. She notes that “there have beenconsiderable redevelopment costs and redevelop-ment issues in changing Alberta’s centralizedhealth system into a regionalized model” and “itis of concern that the funds which were used tobuild and are now used to sustain a regionalizedhealth system are not available for direct patientcare” (p.2). Based upon the results of her study,Wilson (2000a) suggests that:

P regionalization has not improved health careplanning and delivery;

P citizens feel more disenfranchised fromhealth care than they did prior to regionaliza-tion;

P regionalization has not improved com-munication and coordination of care betweenand among regions (there is actually greaterdiversity in programming); and

P Regional Health Authority boards havebecome responsible for issues which areprovincial government issues.

In sum, Wilson states that “a fragmented system,with considerable duplication and health careissues, has developed through regionalization”(Wilson, 2000a, p. 13). Wilson (2000a) concludesthat until it is determined that regionalization is asuccessful format for managing health careplanning and delivery of health services, “itwould be unwise to expect Regional HealthAuthority boards to assume the responsibilitiesassociated with contracting out major surgery tofor-profit firms” (p. 14).

In 1997, rural women who participated in focusgroups indicated that the creation of 17 RHAs

and the development of funding barriers betweenregions had resulted in a competitive environmentand in limitations in access to services for ruralAlbertans (Thurston, Scott and Crow, 1997). Forexample, participants stated that even thoughsome rural people may live closer to the majorcentre of a neighbouring region, they were dis-couraged from accessing services outside of theirown region and in some cases, were refused ser-vice. One participant “indicated her dismay thatthe Alberta health care system was reverting to adysfunctional regionalized system that hadexisted in the province in the 1940’s and 1950’s”(p. 17). Related changes in long-term care ser-vices have meant that people who are elderly ordisabled may be placed anywhere within a regiondepending upon where the long-term beds be-come available. “This situation potentially createstremendous family upheaval and imposes in-creased stress upon family members who are en-couraged to provide support to long-term careresidents” (Thurston, Scott and Crow, 1997, pp.17-18).

Wilson (2000a) discusses the implications for theregions of the population-based funding schemethat was introduced in the 1997/98 fiscal year. Asa consequence of this funding program, regionsmay receive reduced funds because patients havereceived care in other regions (i.e., patients whoare transferred to tertiary care institutions). Theassociated lack of funding permanence is espe-cially problematic in rural regions where stafflay-offs are the most viable method for achievingshort-term savings. As the majority of health careworkers are women, the consequences of suchlay-offs will have a greater impact on womeneither as paid or unpaid caregivers.

More recently, the Alberta Health 1999-2002Business Plan (Alberta Treasury, 1999) describesthe role of Regional Health Authorities as follows(p. 2):


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P Regional Health Authorities will plan anddeliver health services based on evidence ofneeds, with input from residents and com-munity health councils and directions fromthe Minister of Health;

P services will be provided, when appropriate,in homes and communities [emphasis added],not just in hospitals;

P health services will be integrated with betterlinkages between hospital care, home care,community services, mental health services,long term facility-based services,rehabilitation services and public health;

P Regional Health Authorities will work withother organizations in their communities toaddress social, economic and environmentalissues which affect health.

Of particular relevance to the current discussionis the statement that services will be provided inhomes and communities and not just in hospitals.The emphasis in this statement is on where, butnot how, services will be provided. There areunderlying assumptions regarding who will pro-vide care that will be explored below in the sec-tion on “Community-based care and Home Care.”

6. The Delegated AdministrationAct and The GovernmentOrganization Act

The provincial government has favoured privatedelivery of government services since early in itsfirst mandate. For example, The Delegated Ad-ministration Act (Bill 57) was introduced in theFall of 1994 by House Leader Stockwell Day(Legislative Assembly of Alberta, 1994a). Bill 57was designed to facilitate private delivery of gov-ernment services by either for-profit or nonprofitorganizations. Critics were concerned aboutdiminishing legislative authority and account-ability as well as potential for favouritism in the

awarding of contracts (Harrison, 1995). Edmon-ton Journal columnist Mark Lisac (1995) wrote:

The bill brought a distinctive red-market ap-proach to restructuring of government. It wasprivatization, but not complete free-marketprivatization. It was privatization with contin-uing political control...The bill confused pub-lic and private business in many ways. One ofthe certainties seemed to be that cabinet mini-sters would not answer in the legislature foranything done by corporations to whom theyhad delegated responsibility, though the mini-sters would retain significant control overthese corporations. And the province’s audi-tor general would not have free access to re-view any of the agencies (p. 157).

The government eventually withdrew the Billblaming the withdrawal on “a very public mis-information campaign” by the Liberals (Crockatt,1994). The government re-introduced Bill 57 inthe Spring of 1995, accompanied by a discussionpaper distributed to a select number of groups inthe province called “Delegated AdministrativeOrganizations: A Third Option,” to address “anumber of inaccuracies” in part of the Bill(referenced in Harrison, 1995). Harrison (1995)also points out that though Bill 57 was withdrawna second time, The Government Organization Act(Bill 41), which was subsequently introduced,was an onmibus bill that included creation of gov-ernment departments, boards, committees, coun-cils, inter-ministerial and intergovernmental rela-tions, and ministerial authority, as well as severalpages of amendments to various Acts (LegislativeAssembly of Alberta, 1994b). The openness ofsome sections caused concern. For example, sec-tion 9(l) stated that “A minister may in writingdelegate any power, duty or function conferred orimposed on him by this Act or any other Act orregulation to any person’. With regard to fees,Bill 41 not only authorizes the Minister or theMinister’s department to charge fees “for any


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service, material or program the performance ofany function or the doing of any thing,” but alsoallows fees to be charged “by any board, com-mission, council or other agency for which theMinister is responsible” (section 12(l)). Section14(3) allows disposal of government property.

Bill 41 was passed in 1994. The open-endednessof the wording of section 9 in particular appearsto make it possible for the government to accomp-lish many of the aims of the defeated DelegatedAdministration Act with even less public scrutiny.Does “any person”...or “other agency for whichthe Minister is responsible” include corpora-tions—private as well as not-for- profit? Ac-cording to one critic, Bill 41 “allowed ministersto create programs and services, change regula-tions, make loans, sell public property, or transferprograms and services to the private sector whichcould in turn set fees - all without legislative ap-proval” (Harrison, 1995, p. 126). At the time, anunidentified government insider pointed out thatthe intent of Bill 57 could be accomplishedthrough Bill 41 (Crockatt, 1994).

7. A Better Way (I)

Over the next three years (1994-97), a number ofother government documents further illuminatedthe government’s plans for the health system. Forexample, A Better Way: Securing a Plan forAlberta’s Future (Alberta Health, 1994), citesprinciples and criteria that include individual andcommunity responsibility, consumer focus, af-fordability and appropriateness of services (i.e.,need- and evidence-based), and reduction of thecost of health care providers. The document iscommitted to public funding, but also states that“additional health services not based on signi-ficant need will be available, but will require apartial or full direct financial contribution fromthe consumer”(p. 5).

The themes of individual responsibility and

accountability appear again under the section“Strategies for Achieving the Spending Targets.”In addition to downsizing and rationalizing thesystem, the strategies advanced in this sectionalso address shorter acute care stays and shiftingvarious types of care (pre- and post-operative,long-term palliative) to “the community.” Asdiscussed elsewhere in this paper, shorter staysand shifts from the institutional settings to “thecommunity” risk placing caregivers obligationson family members—predominately women—unless formal community-based services are inplace and adequately funded before such shiftsbegin to occur. Though privatization of formalservice delivery is not explicitly mentioned, thestrategies do include rationalizing and restruc-turing of diagnostic services—many of whichhave been privatized (see Taft and Steward,2000). Another strategy was altering Blue Crossco-payments for drugs, which led to co-paymentsfrom individuals increasing from 20% to 30%.Providers were asked to take a 5% rollback inwages. There were some elements of the strategythat had the potential to promote reforms in howproviders work and are supported such as clinicalpractice guidelines (to reduce inappropriateservices), alternative payment mechanisms andworkforce re-adjustment. However, most of thefocus was on overall restructuring with an em-phasis on cutbacks. Later on in the document, aspart of a discussion of the future health system,the issue of basic health services was again raisedin terms of the need to define basic services andthe conditions under which they will be publiclyfunded. The latter statement raises the question ofwhether the document views basic services asdifferent than “medically-necessary” as the lattermust be publicly funded.

Strategies for the second goal included improve-ments in home care and long-term care services.The new home care services would addresscomplex or long-term health needs. However, thehome care strategy also included the eliminationof “non-essential home care services,” whichwere not defined. Additional long-term care


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services included several independent living op-tions, as well as respite and education for familycaregivers. Additional strategies covered a rangeof community-based mental health services, com-munity rehabilitation to replace physical therapyand other fee-for-service rehabilitation services,and availability of medical equipment and sup-plies for home use. For the latter, there is no dis-cussion of whether these will be free of chargenor about the complexity of medical proceduresthat people would be expected to perform at homewith such equipment.

The third goal focussed on shifting an increasingproportion of health care costs to individuals byseeking “financial contributions regardless ofage” (Alberta Health, 1994, p. 7) for universalhealth programs. Seniors would be required topay health care premiums, where before theywere exempt. Also, the income thresholds forpremium assistance for other Albertans would beincreased. The report also recommended healthcare premium costs rise by 20% (only Alberta andB.C. still have premiums). Other proposed in-creases in user charges included home care feesfor “non-medical services,” an increased pro-portion of room and board fees to be paid bylong-term facility residents (though Alberta’srates are among the lowest in Canada—AlbertaHealth, 1997), changes to Blue Cross non-groupbenefits, and discontinued coverage for senior’soptical and dental coverage by Alberta Health.There was an assumption that costs would becovered through an increased Alberta Senior’sBenefit which handles senior’s subsidies.

The fourth goal emphasized personal account-ability and responsibility for health and theproposed strategies with health promotion initia-tives, research and evaluation, information sys-tems (including the “Smart Cards” that werenever implemented), ethics, and information andtraining. The primary focus was education andskill development for individuals, particularly toencourage independence, healthy lifestyles, andappropriate use of the health care system. These

are all important for helping people take actionsto improve and maintain their own health. How-ever, such an individual approach to promotionand prevention assumes health is the responsi-bility of individuals, rather than recognizing thatindividual behaviour and health status are embed-ded in a broader social context.

8. A Better Way (II)

Alberta Health (1995) released a follow-updocument - Better Way II: Blueprint for BuildingAlberta’s Future 1995/96-1997/98. This docu-ment was presented as a business plan, and alsodiscussed the progress on the goals and strategiesfrom the earlier document (e.g., regionalization,wage rollbacks, premium increases, reallocating$110 million to community-based services). Thesecond document also mentions “de-insuringmedically unnecessary services” as part of anonmibus agreement reached with the AlbertaMedical Association, along with developing clini-cal practice guidelines, lab restructuring, andreduced spending on physician services.

The 1995 document was more attentive todiversity (i.e., age, urban/rural, Aboriginal andimmigrant populations, disabled persons) thanprevious documents, but gender was not men-tioned other than in reference to performancemeasures concerning in-patient hospital days andhome care for new mothers. This is consistentwith other Alberta Health documents we re-viewed. There was also more mention of col-laboration with other sectors to address socialissues such as unemployment and underemploy-ment, neighbourhood safety and substance abuse.The new document also added the “the impact ofsocioeconomic and environmental determinantsof health will be considered” (Alberta Health,1995, p. 7) to its principles and criteria. Many ofthe strategies under the four main goals were thesame or similar to those of the 1994 document.

A notable addition under the first goal was to“ensure the development of a framework for


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participation of not-for-profit provider organiza-tions in the Regional Health Authority structure”(p. 11). At the time of regionalization, severalsuch entities (e.g., community health centres,voluntary sector hospitals run by religious organ-izations) were already operating and had a longhistory of community service. In the first year ofplanning for regionalization (1994-95), the role ofthese organizations and their boards was un-certain. In the end, not-for-profit agencies re-tained their own community boards and enteredinto service agreements with the RHAs.

It is interesting to note that the Quebec regionalprivatization scan conducted for the NationalCoordinating Group on Health Care Reform andWomen raised the distinction between shiftingservices to community organizations (“commun-autarisation”) and the commercialization ofservices by for-profit businesses. Both are pri-vate, but one is non-profit and the other is for-profit. The scan noted that some authorsencourage the social economy strategy to keep thefor-profit sector from taking over formerlystate-provided services, as well as encouragingthe public sector to innovate. The Quebec paperalso notes the potential negative result ofinstitutionalization of community services andincreasing control over these by government.5

In discussing characteristics of the health systemin the future, A Better Way II states that “not-for-profit organizations, volunteers, volunteerorganizations and private for-profit operators willcontinue to make significant contributions to thehealth system” (Alberta Health, 1995, p. 15). Thedocument also mentions private alternativeapproaches to health services, dealing mostlywith complementary therapies and counselling.Individuals would contribute to or cover the costsof such services.

What is the present state of some of the usercharges discussed in the Better Way documents?In 1999, premium assistance for health insurancefor non-seniors is such that single individualswith incomes over $7,560 per year and families(two or more people) with incomes over $12,620per year pay full premiums. Full subsidy is onlyavailable for singles under $5,000 and familiesunder $7,500 (Alberta Health, 1999a). Thus, onlythose on extremely low incomes qualify for anysubsidy at all. Premiums are at a flat rateregardless of income once the relatively lowsubsidy thresholds have been exceeded. Thus,lower-income families pay the same premiums ashigher-income families. As eligibility is based onthe previous year’s tax return, those whosuddenly fall on “hard times” (e.g., loss of a job)must wait until the following year for assistance.Single seniors with incomes less than $20,825and couples with incomes less than $32,650 areeligible for full or partial subsidy based onincome. About 35% of seniors pay full premiums.The gender implications of government policy arethat women are more likely to benefit from thesubsidies than men. However, for the non-seniorsin particular, the thresholds are low and morewomen than men will “fall between the cracks”by having too much income to qualify forsubsidy, but not enough to be able to comfortablyafford the full premium amount. High incomeearners, more likely to be men, will spend a lowerproportion of their overall income on premiumsthan lower income earners who are above thethreshold cut-offs.

Current home care policy states that assessment,case coordination, direct professional and per-sonal care (e.g., meals, bathing assistance) ser-vices are provided free for nearly two-thirds ofclients. For those assessed fees, homemaking is$5 per hour and meal services are $5 apiece(Alberta Health, 1999a). The gender implicationsare that unless there is adequate funding fortrained staff to spend time in these communitysettings, the shift to the community will requiremore work by family caregivers, most of whom

5Jocelyne Bernier and Marlene Dallaire, What Price HaveWomen Paid for Health Care Reform? The Situation inQuebec, Montreal: Centre d’excellence pour la santé desfemmes—Consortium Université de Montréal (CESAF), 2000.


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are women. User charges for homemaking andmeal services could be seen as financial barriersfor some families, even though they are on asliding scale based on income and number ofdependents. This could lead to more work forinformal caregivers who feel they must maketrade-offs between the fees and other livingexpenses (e.g., seniors on fixed incomes whoencounter rental or property tax increases orhome repair expenses).

9. Action on Health

The government documents from 1993 and 1996heavily focus on cost saving (often cost shiftingeven though this is not acknowledged as such). In1997, the government began to focus on discus-sion of re-investment in Action on Health:Access, Quality, Stability (Alberta Health, 1997).In this document, it was argued that the cuts of1993 to 1996 were necessary because “costs werespiralling out of control” (p. 13). The documentwent on to indicate that because the governmenthad taken action on the deficit and debt repay-ment, it was now possible to address problemareas (e.g., waiting lists) and put in place a stable,predictable funding base for health. The assertionis questionable as total Alberta public sectorhealth care expenditures per capita in 1999 dol-lars increased by just under $107 (from $1,738 to$1,845) between 1990 and 1993 (i.e., the fouryears preceding the start of major restructuringefforts), compared to a much larger average in-crease for Canada as a whole (almost $176 percapita).6 As well, the rate of increases in percapita expenditures was much less from 1990-93than in the previous four year period of 1986through 1989—when per capita costs increasedby $171 (from $1,489 to $1,660). Thus, the rateof public cost increases was declining prior to themajor restructuring of the mid-1990’s (CanadianInstitute for Health Information, 1999).

The Action on Health document also reiterates a

commitment to public sector control of the healthcare system and coverage of medically-necessaryservices without user fees, extra billing or otherbarriers. Waiting lists were a concern for bothspecialized province-wide services and services atthe regional level. One of the commitments to ad-dress waiting lists was to hire front-line healthcare staff. In addition, it was acknowledged that“there’s a lot of pressure on families when homecare isn’t available,” and that long-term care inrural areas was not always available close to thehomes of other family members. There was acommitment in the document to hiring staff incommunity as well as acute care settings, andimplementing strategies (unspecified) to ensureseniors can get long-term care in locations closeto their homes and families.

There was little specific mention of gender in thisdocument, except for performance measurespertaining to female-specific diseases (i.e., breastcancer screening rates and cervical cancerdeaths), low birth weight newborns, and the pop-ulation funding formula which would account forage, gender and socioeconomic status. Healtheducation for parents of young children was alsomentioned, which is most likely to reach mothers.

The focus on re-investing funds in health care hadthe potential to benefit women, as they make upthe majority of health care workers and informalcaregivers. The question is: to what extent did theproposals of Action on Health actually happen?

According to Alberta Health’s (1999a) web sitesection on health care providers, a additional $22million was added in 1996-97 and $43 million in1997-98 to hire more nurses and other front linestaff—leading to a total increase of 1,401 full-time equivalent positions. According to the Cana-dian Institute for Health Information (CIHI,1999), the number of registered nurses employedin nursing in Alberta rose from 20,751 in 1996 to21,428 in 1997. There was an increase in bothfull-time and part-time positions, and in the num-ber of nurses per 100,000 population (from 751 to763). During any given year, women form ap-

6Per capita expenditures around rounded to the nearest wholedollar


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proximately 97% of the registered nursing work-force in Alberta (AARN, 1997, 1996, 1995).

As well, total public sector health expenditure percapita in Alberta increased from $1,674 to $1,791between 1996 and 1997 (CIHI, 1999). After per-centage decreases of 6.5% and 5.8% in 1994 and1995, there was a 3% increase in spending by theend of 1996, and a further 7% increase by the endof 1997. After being considerably below thenational average (by $100 dollars are more) from1994-96, 1997 expenditures brought Alberta closeto the national average again. CIHI presentedfurther projected public expenditure increases for1998 and 1999 (to $1,982 for 1999), but actualnumbers are not yet available. Thus, there has been some re-investment inAlberta’s health care system. Health careworkers, however, have questioned whether it hasbeen adequate. For example, the United Nurses ofAlberta’s contract bargaining of 1999 addressednot only wage and salary issues, but alsoworkload, overtime requirements, weekend andshift work, and parity of facility andcommunity-based nurses. Documents from theUNA suggested that managers had unrealisticexpectations and did not recognize the stressfulworking conditions of nurses, particularlyworkloads which were seen as tied to ongoinginadequate staffing levels. Despite averting apotential strike and winning wage increases andsome improvements in working conditions, theunion’s concerns about staffing and workloadremain (UNA, 1999). This re-investment focuscontinues with the 2000/01 budget, particularlyfor the hiring of more nurses (Alberta Treasury,2000b). It is too early to determine the extent towhich this will benefit providers and users of thehealth care system.

The Provincial Health Council of Alberta7

(1997a) also expressed concerns about strain onhealth care providers:

Many individual service providers have beenprofoundly affected by job loss, fear of jobloss and job change. Staff resignations andreassignments have, in some cases, led tofrequent changes in personnel. This createsdifficulties in maintaining standards of care.Staff are sometimes performing unfamiliarroles without the support that was availablebefore restructuring. We have been told thatmany providers feel uncertain, devalued andhighly stressed. Many of these feelings arebrought on by frustration resulting from lossof control or any sense of participation indecision-making (p. 11).

The Council expressed concern that low moraleand job satisfaction among providers in turn af-fects the availability and quality of care throughabsenteeism, long-term disability leaves, turn-over, recruitment difficulties, and low levels oftrust that can lead to resistance to change and lackof concern for patients and colleagues. The Coun-cil also acknowledged, however, that in somecases staff reductions have led staff to collaboratein new ways.

10. The Health Statutes Amendment Act

Bill 37 (The Health Statutes Amendment Act) of1998 was the first attempt by the government to

7The Provincial Health Council was established by the Ministerof Health in 1995 to monitor and report to the legislature theprogress of health reform in Alberta. It was disbanded in 1998.There is a new Premier’s Advisory Council on Health in theplanning stages. It will be chaired by former Deputy PrimeMinister Don Mazankowski (presently chair of the Institute ofHealth Economics) and will advise the premier and the govern-ment on health system sustainability (Alberta Health andWellness, 2000b).


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regulate the provision of surgical services pro-vided outside of public hospitals. Much of theBill addresses accreditation of facilities andqualifications of practitioners, as well as infor-mation required by the Minister to make deci-sions about the use of surgical facilities. The useof the term “non-hospital surgical facility” (de-fined as a “facility at which insured services,together with related facility services, are pro-vided”), was open-ended enough that it was dif-ficult to see how it would prevent the mixing ofinsured and uninsured services within a facilityand thus, the charging of fees for services thatmight normally be covered.

A panel commissioned by Alberta Health to re-view Bill 37 concluded that the Bill and itsamendment were complex pieces of legislationthat could be easily “misconstrued.” The panelmembers recommended that:

P a patient should be able to insure against theresidential component cost of care where thatcost may be legitimately charged in ahospital, auxiliary hospital, or nursing home;

P the distinction between hospital and non-hospital procedures should be based on theprinciple of required recovery time (i.e., thesafe discharge of the patient within 12 hoursof completion of the surgical procedure);

P specified surgical procedures that complywith the 12-hour safe dischargerecommendation (cited in Appendix C ofAlberta Health, 1999b) may be provided in an“approved hospital or a non-hospital surgicalfacility” and those that are not listed or do notcomply must be provided in an approvedhospital;

P a temporary measure be implemented toprovide the Minister with the legislativepower and the responsibility for the regula-tion of approved hospital facilities providingboth uninsured or insured services within theAlberta Health care system; and

P the legislation be replaced with amendmentsto three separate acts (i.e., The Alberta HealthCare Insurance Act, The Hospitals Act andThe Medical Profession Act (Alberta Health,1999b).

The government eventually withdrew this bill inthe face of strong opposition (Taft and Steward,2000).

11. Health Summit ‘99

The Provincial Health Council reports released in1997 had expressed concern about the strains thathad been created in the health system (ProvincialHealth Council of Alberta, 1997a, b). The reportsindicated that, while some elements of the systemhad been reorganized, health reform had not takenplace. Following the release of these reports,Halvar Jonson, the Minister of Health, announcedHealth Summit ‘99. The Summit was touted as anopportunity for Albertans to assist in the develop-ment of strategies on important directions for thefuture of Alberta’s health system.

Two hundred participants were invited to Calgaryon February 25-27, 1999 to debate four questionsand to strategize the future of the health system.The participants included approximately 100 rep-resentatives of people working in the healthsystem, as well as approximately 100 randomlyselected members of the public. The four ques-tions that were debated were:

P What is essential in Alberta’s health system?P What changes should be made in how health

services are delivered and managed?P What responsibility do individuals have for

their own health?P How much money is enough to sustain our

publicly funded health system? (AlbertaHealth, 1999c, p. 4)

Prior to answering the first question, participantsdiscussed the principles and values that theywanted to guide Alberta’s health system. Several


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of the principles strongly reaffirm the principlesof the Canada Health Act with particular em-phasis on public funding and administration andequality of access. The participants chose not toidentify specific components of the system thatare essential or non-essential. The general con-clusion was that “priorities cannot be placed onessential components: all components are im-portant to different people at different times”(Alberta Health, 1999c, p. 20). There was generalagreement on the need to expand primary healthcare and prevention and promotion strategies. Inthe final report from the Summit, it is indicatedthat participants were also clear in their view thatresponsibility for health is more than an indivi-dual responsibility. It is a responsibility sharedamong “individuals, families, the health system,communities, different levels of government, andother sectors outside the health system” (AlbertaHealth, 1999c, p. 26). There was no consensusamong the participants on the appropriate level offunding for Alberta’s health system. “People needto come to a consensus on what an appropriatesystem is for the province before decisions can bemade about how much funding is needed”(Alberta Health, 1999c, p. 30).

12. Health Information Systems: The Health Information Act

In 1997-98 the government of Alberta began tolay the groundwork for a new health informationnetwork called “alberta we//net.” Part of thisgroundwork included the initiation of legislationthat would balance protecting the privacy ofhealth information and sharing information toimprove health and the health system. The HealthInformation and Protection Act (Bill 30)was firstintroduced in the Spring of 1997. The AlbertaMedical Association (AMA, 1998) issued a posi-tion statement summarizing a number of concernswith the proposed Act. While the AMA concededthat the use of health information could advancethe public good, the Association had some con-cerns regarding the logistics of managing the in-formation. The specific concerns included:

P violation of the patient-doctor relationship;P failure to protect personal identifiable health

information; andP a profound operational and financial impacts

for physicians.

In the face of strong public opposition whichprimarily centred around the lack of control thatindividuals would have over the release of per-sonal health information, the government with-drew the Bill. After further revisions, the Bill wasagain introduced to the legislature in November1999, this time as The Health Information Act(Bill 40) The change in the name of the legisla-tion is of note. Although there is a stated com-mitment to the protection of personal privacywithin the summary documents, the conditionsunder which information could be accessedwithout consent may be broadly interpreted. Forexample, the “custodian” may access informationwithout an individual’s consent to determine ifsomeone is eligible to receive a health service(i.e., to see if they are registered for AlbertaHealth Care Insurance or other benefits, AlbertaHealth and Wellness, 1999). There was heateddebate in the legislature about the openness of theproposed legislation. The Official Oppositionproposed a number of amendments to the Billwhich would increase the level of control overpersonal health information and ensure that thelegislation cover private as well as public healthcare providers (Alberta Hansard, December 7,1999). The government closed debate on this Billand it was passed in the legislature on December8.On December 8, a question posed in the legisla-ture by the Liberal labour critic highlighted someof the concerns about this Bill:

As contractors with health information custo-dians, will private hospitals have access to thegovernment’s health information database sothey can screen patients and avoid the cashflow uncertainty that comes from treatinghigh risk and high cost patients? (AlbertaHansard, December 8, 1999)

The potential for private funders and providers to


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screen out people who are at higher risk woulddifferentially impact people who earn lowincomes (e.g., women, people who are disabled).

13. Bill 11: The Health Care Protection Act

With The Health Information Act in place, theAlberta Government proceeded to introduce Bill11, The Health Care Protection Act. The intro-duction of this legislation has sparked substantialfederal and provincial debate. We will analyse theBill in the context of that discourse focussing onthe background leading to the proposed Bill andits implications.

In late 1995, the federal government began towithhold transfer payments to penalize Albertafor allowing private clinics to charge facility feesto people receiving medically insured services. In1996, while attempting to resolve this issue, thefederal and Alberta provincial health ministersagreed to 12 principles (see Appendix B) out-lining the Alberta approach to health caremanagement (Alberta Health and Wellness,2000a).8 These principles had originally beendrafted in Alberta through consultations betweenAlberta Health and the Alberta Medical Associa-tion. Seven of the principles specifically discussissues related to private purchase and provision ofhealth services, but it is principle 11 that is per-ceived to have put in place much of the ground-work for the introduction of Bill 11. This prin-ciple, as stated originally, recognized that “physi-cians can receive payment from both the publiclyfunded system and fully private systems” (AlbertaHealth and Wellness, 2000b). In the Fed-eral/Provincial Working Agreement on the

principles, it was stated that:

The same physician can practice in both thepublic and private system if he/she is offeringinsured services which are fully paid for bythe public system and non-insured serviceswhich are paid for privately. All medicallynecessary services are insured services. Aservice is non-insured when deemed to be notmedically necessary in that it does not meet aClinical Practice Guideline (CPG) whichwould include criteria of medical condition,appropriate timeframe, etc., or is otherwisedetermined to be not medically necessarythrough a medical decision.... (Quoted inArmstrong, 2000)

Armstrong (2000) raises the concern that a physi-cian has some flexibility to decide on medicalnecessity for a particular patient, and that he/shecould make more money by deciding the pro-cedure is not medically-necessary. Women’shistory with the health system has been charac-terized by bad experiences, ranging from miso-gyny to paternalism. Only through concertedactivism, including fighting for the right to be-come physicians, have women succeeded inmaking the health system more appropriate(Strong-Boag, 1994). Many women, however, donot fully trust male physicians (Webb andOpdahl, 1996); therefore, why would women as apopulation want the medical profession to decidewhat was medically-necessary?

Health economist Robert Evans of the Universityof British Columbia has pointed out that priva-tizing health services has the effect of redistri-buting income from the less to the more healthyand wealthy (Evans, 1997). Evans also points outthat a shift to more private sources of paymentwill be regressive for those on low incomes, usingthe example that insurance premiums are notlinked to income. This is an issue in Alberta evenwithin the public system, as Alberta is one of onlytwo provinces that charge Medicare premiums.These redistributive and regressive effects again

8After several attempts, we were able to obtain an original copyof these principles from Alberta Health and Wellness. It wasindicated that it was just by chance that someone had kept acopy. We sincerely appreciate the cooperation of the staffperson who shared this public information with us.


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hit women hardest as a group, as women on ave-rage earn less then men. Also, Armstrong andArmstrong (1996) point out that women are morelikely than men to be in part-time work, and thatthe recent gains in self-employment have beenmore pronounced for women. These types ofwork are less likely to have employer-paid pre-miums for either Medicare or private insurance. Ifthe continuing development of private health carefacilities in Alberta leads to de-insuring of moreservices or failure to insure new types of treat-ments, women will be particularly impacted. OnApril 4, 2000, in a publicly televised discussionof Bill 11 in the Alberta legislature, the Premierindicated that the intent of the Bill was to protectthe public health system and to create an ad-ditional tool to deal with waiting lists. The abilityof the Bill to adequately address either of theseissues has been questioned (CUPE, 2000; Barer,Evans, Lewis, Rachlis, and Stoddart, 2000;Rachlis, 2000; Wilson, 2000b).

The title of the Bill is The Health Care ProtectionAct; however, the primary focus of the proposedlegislation is on practices related to acute care(i.e., care provided in public hospitals and ap-proved surgical facilities). A departure from thisfocus is found in Part 4 of the Bill where itaddresses the formation of the Premier’s Advi-sory Council on Health. This Council would con-sist of “persons appointed under the regula-tions”(Alberta Health and Wellness, 2000b, p.14). The regulations have yet to be defined. Themandate of the Council would be “to provideadvice to the Premier on the preservation andfuture enhancement of quality health services forAlbertans and on the continuing sustainability ofthe publicly funded and publicly administeredhealth system” (p. 14). It should be noted that thisdoes not state that the Council will provide adviceon the preservation and future enhancement of thepublic health system.

The preamble to the proposed legislation affirmsthe commitment of the Government of Alberta to

a publicly funded and publicly administeredhealth system and to the principles of the CanadaHealth Act. However, the section of the Bill thatdeals with the designation of surgical facilitiesincludes a clause that would permit the Ministerto consider “any other factors the Ministerconsiders appropriate” (Alberta Health, 2000b, p.9). These “other factors,” left to ministerialdiscretion, could override concern for whether theprovision of such services would have an“adverse impact on the publicly funded and pub-licly administered health system or impair thegovernment’s ability to comply with the CanadaHealth Act” (Alberta Health, 2000b, p. 9). In alegal opinion obtained by the Canadian Union ofPublic Employees (CUPE, 2000) the law firm ofArvay Finlay states that “the Bill’s provisionsviolate Canada Health Act requirements dealingwith universality, accessibility and compre-hensiveness and may threaten the public adminis-tration requirement” (p. 1). In addition, it is statedin the Bill that “no decision made by the Ministerin the exercise or purported exercise of power...under this Act may be questioned or reviewed inany court” (Alberta Health, 2000b, p. 11). Thelevel of ministerial control and the exemption ofthe Minister from legal questioning has also beenraised as a concern in public discussions re-garding this Bill.

The opening section of the Bill states that “noperson shall operate a private hospital in Alberta”(Alberta Health, 2000b, p. 3) and that surgicalservices may only be provided in public hospitalsor approved surgical facilities. “Approved sur-gical facilities” are distinguished from public andprivate hospitals by stipulating that the primaryfunction of such facilities is to provide a limitedrange of surgical services. It is also stated thatmajor surgical services can only be provided inpublic hospitals (p. 3). The distinction betweenwhat is major and what is not major surgery hasnot been clearly defined. Although Bill 11 givesthe College of Physicians and Surgeons theauthority to decide which procedures can be


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safely provided in surgical facilities, someparameters for such decision are provided in theBill. For example, “uninsured in-patient surgical”services may be provided in such facilities andare defined as services that require “a medicallysupervised post-operative period of care exceed-ing 12 hours” (p. 18).

By indicating that approved surgical facilitiesmay provide uninsured surgeries that requireovernight stays, there is an unclear distinctionbetween major and “not major” surgery. Dr. TomNoseworthy, former head of the Royal AlexandraHospital in Edmonton and present Chair of PublicHealth Sciences at the University of Alberta,points out that minor procedures are now doneprimarily as day surgery and people are notadmitted to hospital overnight unless their sur-gery is major (Pederson, 2000a). Noseworthygenerally favours a role for private servicedelivery with public financing (as currentlyexists), and yet he raises concerns about extend-ing private delivery to include surgical facilitieswith overnight stays, noting that such clinicswould no longer be doing minor surgery.

There is also some question about whether theprivate health care facilities reduce waiting lists.Noseworthy (1999) pointed out in his address tothe 1999 Health Summit that in Britain, waitinglists in the public National Health Service arelongest for conditions that are the “bread and but-ter” of private hospitals. Noseworthy also spokeof his experience in the late 1980s working inintensive care units in Australia to link the issuesof waiting lists to the ability of physicians towork in both the public and private systems:

It seemed as if physicians attempted to finishrounds as early as possible in the morning, sothat they could go to the private hospitalswhere they would spend the balance of theday and, or course, garner the majority oftheir income. The private system was verywell capitalized. There was no question aboutthe fact that physicians created different

streams of patients and allowed those lessable to pay to stack up in a public line, whilethey rapidly serviced those that had cash onthe barrel head. The myth propagated is that aprivate parallel system helps the waiting listsin the public system. The truth suggests oth-erwise (p. 9).

Others have also noted that “waiting lists existbecause too few resources have been directedtoward quality control and resource management”(Davies, 1999, p. 1470).

Although Bill 11 states that it will allow neitherdirect billing for medically-necessary service nor“queue- jumping,” private clinics will be able tobill for uninsured extra services. Thus, there stillappear to be incentives for physicians practisingin both public hospitals and private clinics todirect people to the private side. Unless doctorsare prohibited from working in both systems (thekey principles developed in 1995/96 encouragephysicians to work in both systems), or conflict ofinterest guidelines are introduced to forbid physi-cians from referring patients to clinics in whichthe physician has a vested interest. A study ofcataract surgery in Alberta (Armstrong, 2000)found that not only were private surgical cont-ractors more costly to the provincial public healthcare plan, but also that patients were being of-fered enhanced uninsured services that in somecases also reduced their wait time for service.Waiting lists for publicly insured operations werelonger for surgeons operating in both the publicand private systems than for those operating inthe public system alone. Also, the enhanced“soft” or “foldable” lens option was more ex-pensive ($250 to $750 per eye) in Calgary whereall publicly insured cataract surgeries are con-tracted out by the Regional Health Authority toprivate clinics, than in Edmonton ($250-$425 pereye) where only 20% are contracted out. In Leth-bridge, where all cataract surgeries are done inthe public system, the enhanced product is pro-vided at no charge (and costs the health region


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less than $100 per eye). While there are somelimitations of this report, it raises issues that mustbe addressed, the potential for conflict of interestand the need for regulation of such conflicts.

Under Bill 11, approved surgical facilities will beable to provide insured surgical services undercontract to a Regional Health Authority. Giventhe need to generate profits for shareholders, it isquestionable whether such private facilitieswould be willing to share in the costs associatedwith negotiating, implementing and monitoringcontracts with Regional Health Authorities(Wilson, 2000b). In fact, Bill 11 specificallystates that the money for contracts will come outof the RHA budgets (Alberta Health and Wel-lness, 2000b, p. 7). Money that is required forsuch contracting services will not be available fordirect service provision. It is equally unlikely thatit will be a priority for such facilities to assumeresponsibility for linking patients to servicesprovided through the public health system (i.e.,home care, diagnostic and intensive care ser-vices). This implies that patients who requireassistance during or following surgery will haveto acquire such services themselves. These imp-lications have obvious consequences for care-giving responsibilities of family members,primarily women.

Even within the public system, designating sitesfor different levels of acuity (i.e., major or minor)has proven complicated. For example, during theearly stages of regionalization, the Capital HealthAuthority attempted to divide surgical care intohigh and low acuity settings; concentrating highacuity procedures in two hospitals and designa-ting other hospitals (which had been downsized to“community health centres”) for day surgery andlow acuity in-patient surgery (Hamilton, Letour-neau, Pekeles, Voaklander, and Johnston, 1997).The intent was to develop specializations forvarious sites in the hope of finding efficiencies todeal with funding cuts that accompanied

regionalization. In studying the impact of thissystem on physicians, Hamilton et al.(1997)found a 3.5-fold increase in the number ofsurgeons working in more than one site after thisrestructuring compared to before. They note thatmost surgeons do both high and low acuitysurgeries, thus were working in two sites on aregular basis, with increased reliance on surgicalhouse staff (with whom they spend less time andare thus less familiar with the limits of theirskills), interference with continuity of care,increased commuting time for both surgeons andmedical residents, and less contact betweensurgeons and residents.

The Capital Health study focussed on providersrather than health outcomes, and has somelimitations in terms of being retrospective and nothaving consistently comparable data from beforeto after regionalization. There was no change ininpatient mortality for surgical inpatients duringthe short timeframe of the study (1995-96).Capital Health has since abandoned this system ofhigh and low acuity hospitals. We mention it herebecause some of the same problems could arise ifsurgeons are doing both high acuity surgeries inpublic hospitals and lower acuity surgeries inprivate clinics. As private clinics are not anintegral part of the public system, there wouldlikely be even more discontinuity when surgeonspractice on multiple sites.

This Bill has also raised concerns about de-insurance of more services that could then bepicked up as uninsured user-pay procedures, orfurther privatization of public services. Anexisting example of privatization of publicservices in Calgary is the transfer of the GraceHospital (which focussed on women’s health)9 tothe private sector. This previously public facilitynow houses the Health Resources Group (HRG),

9The Grace has since been relocated to the Foothills Hospitalsite and renamed the Grace Women’s Health Centre.


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a private clinic that is particularly interested incontracting with the Regional Health Authorityfor overnight stays (Taft and Steward, 2000).

A recent study of hospital utilization patterns inAlberta found that reductions in both hospitalseparation rates (i.e., cases admitted to hospitaland average lengths of stay) led to a 40%decrease in Alberta’s age-sex standardized hos-pital days rate between 1991-92 and 1996-97(Saunders, Bay and Ahbhai, 1998). The results ofthe study also indicate that the reduction of thehospital days rate slowed down in 1996-97 be-cause average lengths of stay increased eventhough the separation rate continued to decline.The researchers noted that average case-intensityincreased over that time period, “suggesting thatsicker, more resource-intensive patients wereadmitted to hospitals”(p. 15). The researchersalso pointed out that hospital utilization was al-ready on a downward trend in the five years priorto 1991-92 (a 26% drop in the standardized daysrate) and that health reform and associated fund-ing reductions accelerated the trend. There havebeen concerns raised about the impacts on womenof short hospital stays and the shift from acutecare institution to community care. There is noindication (and some doubt) that these concernswill be addressed in the shift toward privatefacilities (i.e., that private clinics would allow, atno charge, longer stays than public hospitals).

Concerns have also been raised about the impli-cations of Bill 11 for the NAFTA. Rachlis (2000)states that under this agreement, “health care isprotected only to the extent that it is considered asocial service carried out for the public good” (p.5). If the Bill is passed, health care may be treatedas any other sector of the economy that is not“explicitly and exclusively reserved for publicaction” (Barer et al., 2000, p. 3). That is, healthcare in Canada may be open to global competitionand, once it occurs, may be irreversible. It hasbeen argued that private for-profit hospitals al-

ready exist in Canada (e.g., the Shouldice Clinicin Ontario) and therefore the NAFTA has alreadybeen tested and proven innocuous with respect tohealth care. These arguments do not acknowledgethat the Shouldice Clinic and other small facilitiesexisted before the Medical Care Insurance Act(1966) and were grandfathered into private hos-pital legislation. New, for-profit facilities havenot been licensed in Ontario, for example, since1973 (Rachlis, 2000).

For-profit institutions primarily operate on anincentive for profit rather than a concern forpublic benefits. In Canada, a motivation for profitis an accepted element in many sectors of the eco-nomy, but control of the profit motive has been aforce behind much of the federal health carelegislation since the early1960s. To ensure thatprofits are made and shareholders benefit, privatefor-profit facilities attempt to reduce costs wherepossible. Potential sources of cost savings includereduced labour costs and increased costs for thepurchaser (i.e., individual citizens or RegionalHealth Authorities). Barer et al. (2000) suggestthat reduced labour costs may be accrued byeither reducing the numbers of staff or shiftingservices from union to non-union environments inwhich case there is no improvement in efficiency.In their critique of Bill 11, Barer et al. (2000)state that private payment shifts costs of care dis-proportionately to those with lower incomes. InAlberta, we know that the majority of peopleliving on low incomes are women (CSWAC,1999).

In the face of opposition to Bill 11, the Premierannounced on February 10 that he was sendingout “truth squads” to counter “the malicious mis-information being circulated about the govern-ment’s private health care plans”(Johnsrude,2000a). The government planned to hold Round-tables across Alberta to inform people of theintent of Bill 11. In this article, Premier Kleindistinguished this approach from town hall


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meetings “where people can get up and yell andshout and so on.” This again underscores theAlberta Government’s negativity toward thosewho oppose its views. Though the focus on the“truth squads” has been retracted, the governmentcontinues to refer to opponents as misinformed,as seen in a recent televised debate on the Bill.

In early April 2000, the government begandiscussing amendments to the Bill, includingtightening procedures to prevent “queue-jumping” and addressing conflict of interest(Geddes, 2000). Shortly thereafter, the federalminister of health suggested more substantiveamendments, including restrictions on insuredand uninsured services being offered by the sameproviders and banning overnight stays (Pederson,2000). On April 11, 2000 Premiers Ralph Klein’sgovernment announced that it would introduce amotion to block any further amendments andforce a vote on second reading of the Bill as earlyas that night (Johnsrude, 2000b).

14. Community-based Care and Home Care

In 1997, Casebeer, Scott and Hannah exploredstrategies for shifting service delivery patternstowards increased community-based care in oneRegional Health Authority in Alberta. At the timeof the study, regionalization had been in place fortwo years and it was clear that the managementteam in the region was still some distance fromdefining what community-based care was to be.In some instances, key informants described theshift as a change in the location of service deli-very without acknowledging that need for achange in the way services are provided. Therewas also a lack of agreement among the studyparticipants regarding the role of volunteers inproviding community-based care. Some saw it asan opportunity to “mobilize the community forvoluntarism”(Casebeer, et al., in press) while

others acknowledged that it could not be expectedthat such services would be provided on a volun-tary basis. As already noted in The RainbowReport, in 1989, 6 of 10 volunteers in Albertawere women. The suggestion that community-based care may be equated with increasedreliance on voluntarism thus has direct impli-cations for women.

The Provincial Health Council of Alberta (1997a)indicated that despite the government’s indica-tions that there had been more funding for com-munity and home-based services, the Council hadno details on how the funding was being used andwhether (a) Albertans have undergone personalexpense and effort to supplement services thatsupport early discharge from hospital, or (b)demands to support early discharge have ad-versely affected other community services thathelp people with chronic conditions. The Council(1997a) concludes:

The whole issue of the consequences of“off-loading” costs by removing them frompublicly funded health services and makingthem the responsibility of individual Alber-tans or other areas of the community needs tobe rigorously examined and weighed in thebalance to properly assess the benefits ofreform (p. 15).

Even though the Council recognized off-loadingand its potential negative impacts, it did notacknowledge that women bear a disproportionateshare of informal caregiving. In a section of thereport entitled “Developing capacities in familiesand personal networks contributes to healthreform” the Council cited the 1996 survey resultsthat 40% of respondents who provide health caresupport to a family member found it to be a minorinconvenience and 16% found it a major dis-ruption. The Council proposed that “additionaleducation and training, or improved availabilityof respite care might assist Albertans in providingsupport without undue strain” (Provincial HealthCouncil, 1997a, p. 23) Thus, the Council took


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family caregiving as a given, rather thanquestioning it. As the Council was a minis-terially-appointed body, it did not have a mandateto go beyond monitoring and reporting on reformsas defined and implemented by the government.Within that mandate, it did provide a more criticalanalysis than other bodies within government.

More recent studies have demonstrated that asubstantial percentage of adult Albertans are pro-viding health care support to a family member. Aprovincial survey, commissioned by AlbertaHealth and Wellness and conducted by the Uni-versity of Alberta Population Research Labor-atory, found that 44% of females and 32% ofmales provided such support in 1999 (Northcottand Northcott, 1999). Of those providing support,44% said it was a minor inconvenience and 12%said it was a major disruption of their normalactivities. Women were more likely than men tosay that providing support was a majordisruption. The survey did not assess amount orlevel of support provided, so we are unable toexamine hours and types of work by genderwhich might explain gender differences in per-ceptions of inconvenience. Other researchers(Armstrong and Armstrong, 1996), however, havepointed out that in most cases women take on agreater proportion of caregiving tasks than men.In comparison with 1996 survey statistics usingthe same questions and methods (cited in Pro-vincial Health Council of Alberta, 1997a), thereis a slightly lower percentage of respondentssaying provision of support is a major incon-venience (12% in 1999 compared to 16% in1996). A slightly higher percentage viewedprovision of support as a minor inconvenience(44% in 1999 versus 40% in 1999). Thus, we arenot seeing substantial shifts in the public’sperception of their involvement in providinghealth care support to family members, despitere-investments in health care from 1996-97onward.

Noseworthy (1999) expressed similar concerns to

the Health Summit ‘99 about how an increasingportion of the costs of providing community--based care falls to patients and their informalcaregivers, but he did not acknowledge thegendered nature of caregiving. Noseworthy was amember of the National Forum on Health, whichrecommended a publicly-funded national homecare program. (National Forum on Health, 1997).

By examining Alberta Health annual reportsbetween 1996-1999, Wilson (2000a) illustratesthat, despite a commitment to increasing supportfor home care and community health, the pro-portion of health system funds devoted to theseareas has remained relatively constant (4.7% in1996-97, 4.9% in 1997-98, 5. 1 % in 1998-99). Atthe same time, hospital downsizing resulted in theremoval of approximately one half of all inpatientacute care beds across Alberta (i.e., from 12,000beds to 6,260 beds in 1998/99) (Wilson, 2000a).Wilson notes that a consequence of hospitaldownsizing has been the “shift of caregiving andcost of care to the family” (Wilson, 2000a, p. 4).Morris et al. (1999) cite statistics from the Cana-dian Home Care Association noting that in theearly days of health restructuring in Alberta, thegovernment cut $749 million from acute care butadded only $110 million to home care over threeyears.

There is also the issue of out-of-pocket costs. Forexample, Morris et al. (1999) expressed concernabout home care recipients and their informalcaregivers picking up costs (e.g., meals, drugs,medical devices) that would be covered if therecipient was in a hospital. The limited hours andservices for which recipients are eligible also leadto them having to pay fees for services beyondthat level. This may be reflected in the upwardtrend in private coverage in Alberta which, inother provinces.


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Another area where provider strain is reported ashigh is among paid home care staff. For example,Morris et al. (1999) found low wages, irregularhours, inadequate training and high turnoveramong workers (mostly women). Workers ob-served that these conditions resulted in lack ofcontinuity of care, staff shortages, waiting lists,health risks to both workers and recipients andimpoverishment. Some home care workers re-ported working several jobs to make ends meet,and others were living below the poverty line.Morris et al.(1999) also discuss “deprofessional-ization” of home care work, isolation of workers,lack of adequate training, exposure to violence orharassment, and the absence of professional as-sociations or unions (which has had a negativeimpact on wages). They found some examples ofhome care workers, as well as family members,picking up out-of-pocket costs (e.g., equipment,meals, drugs) for low-income clients; costs thatwould be covered in hospital. Morris et al. (1999)

point out that as there is more competitionbetween for-profit and not-for-profit providers(e.g., VON) there is likely to be continued down-ward pressure on wages and that for-profit pro-viders will not reinvestment money back intoservice provision.

Representatives of provincial health ministershave already indicated that they prefer to havetransfer payments restored to use as they wish intheir existing health care systems, rather thanparticipating in expanded home care and com-munity care, which they call “boutique programs”(Mackie and Sequin, 2000). Given the govern-ment’s record of expecting women to put theirfamilies first and volunteer their unpaid labour aspublic services are cut back, it is unlikely thatAlberta would use extra funds to design the typeof home care program that would not rely to alarge extent to the unpaid work or underpaid ofwomen.

PART

3 CONCLUSIONS

The current Conservative government holds 64 of83 seats in the provincial legislature, with theopposition Liberals and New Democrats holding16 seats and one seat respectively. Through par-ticipation in public forums and town hall meet-ings focussed on health care restructuring, Alber-tans have added their voices to those of theirelected officials; however, legislative and publicopposition to the current privatization policyagenda has done little to alter the course or thepace of change. Despite the level of public dis-course regarding the current legislation, there hasbeen little public discussion of the gendered im-pacts of the move toward privatization.

We have demonstrated that there has been a long-standing commitment in Alberta to increasing therole of the private sector in health care. While werecognize that the private sector is currently andwill continue to be an integral part of the healthsystem, we advise caution. In this report, we con-ducted gender-based analysis of key health policy

events that took place in Alberta between 1989and 2000. This analysis highlights the seriousimplications that increased health care privatiza-tion will have for women (such as lower wages,less secure jobs, out-of-pocket costs, informalcaregiving obligations). Before current legisla-tion is passed, and before any further legislationis introduced, the implications for all citizens,most particularly for women, must be compre-hensively and systematically examined usingstrategies for meaningful public participation indecision-making.

If we are to preserve the environment on a sus-tainable basis, achieve gender equality, takeinto account the legitimate claims to identity ofcertain minorities within existing democraticstates, and foster the development of culturaloptions beyond commodification, we requirean activist democratic state. (Broadbent, 1999,p. 92)

Appendix AChronology of Alberta Premiers

Alexander RutherfordArthur SiftonCharles StewartHerbert GreenfieldJohn BrownleeRichard ReidWilliam AberhartErnest ManningHarry StromPeter LougheedDon GettyRalph Klein

LiberalLiberalLiberalUnited Farmers of AlbertaUnited Farmers of AlbertaUnited Farmers of AlbertaSocial CreditSocial CreditSocial CreditConservativeConservativeConservative

1905-19101910-19171917-19211921-19251925-19341934-19351935-19431943-19681968-19711971-19851985-19921992-

Source: Marsh, J. (Ed.) (2000), Canadian Encyclopaedia—Year 2000 Edition. Toronto, ON: McLellan and Stewart.

Appendix BPublic/Private Health Services:The Alberta Approach

KEY PRINCIPLES

P ensure reasonable access to a full range of appropriate, universal, insured health services, withoutcharge at the point of service.

P Alberta retains the authority and responsibility to manage the publicly funded health care systemin the province.

P recognize the demands from both the public and health professions for an approach to health ser-vices that is consistent with long term sustainability and quality.

P ensure a strong role for the private sector in health care, both within and outside the publiclyfunded system.

P public and private sector should work together to provide patient choice, quality of service, andeffective outcomes as the first priority.

P Regional Health Authorities assess health needs in their regions and be funded to provide appro-priate health services in accordance with the health needs assessment.

P consumers have the right to voluntarily purchase health services outside assessed need.P maintain the restrictions on the role of private insurance, while introducing measures to expand

the opportunities for the private sector to deliver services within the single-payer envelope.P private clinics should have the option of becoming completely private (patient pays), or allowing

them to enter into a variety of funding arrangements with the public sector to cover the full costsof insured services.

P there is a place for medical training in both public and private settings, however, care must betaken to ensure there is no deterioration in the world class training physicians currently have.

P recognize that physicians can receive payment from both the publicly funded system and fullyprivate sources.

P province must at all times be able to demonstrate “reasonable access” to insured health serviceswith no fee at point of service, or penalties would apply. An understanding is necessary on themechanisms to determine and measure “reasonable access.”

Source: Communications Branch, Alberta Health and Wellness (2000).

References

Alberta Advisory Council on Women’s Issues(1996a). A Decade of Challenge and Change: AReview of the Activities of the Alberta AdvisoryCouncil on Women’s Issues. Edmonton, AB: Au-thor.

Alberta Advisory Council on Women’s Issues(1996b). Breadmakers and Breadwinners: TheVoices of Alberta Women. Edmonton, AB: Author.

AARN (1997, 1996, 1995). Membership Statistics.Edmonton, AB: Alberta Association of RegisteredNurses.

Alberta Hansard (1999). December 7 and 8. Edmon-ton, AB: Government of Alberta.

Alberta Health (1991). Partners in Health: The Gov-ernment of Alberta’s Response to the Premier’sCommission on Future Health Care for Albertans.Edmonton, AB: Author.

Alberta Health (1993). Health Goals for Alberta:Progress Report. Edmonton, AB: Author.

Alberta Health (1994). A Better Way I: A Plan for Se-curing Alberta’s Future. Edmonton, AB: Author.

Alberta Health (1995). A Better Way II: A Plan forSecuring Alberta’s Future. Edmonton, AB: Au-thor.

Alberta Health (1997). Action on Health: Access,Quality, Stability. Edmonton, AB: Author.

Alberta Health(1999a). Health Services for Albertans:Community-based Services, Retrieved from<www.health.gov.ab.ca/services/sercomm.htm>;AHCIP—Premiums and Rates,<www.health.gov.ab.ca/ahcip/ premiums.htm>; Healthcare providers,<www.health.gov.ab.ca/about/boutprov.html>, April 5,2000.

Alberta Health (1999b). Report of the Bill 37 ReviewPanel. Edmonton, AB: Author.

Alberta Health (1999c). Health Summit ‘99—FinalReport and Recommendations. Edmonton, AB:Author.

Alberta Health and Wellness (1999). A summary ofAlberta’s New Health Information Act. Edmonton,AB: Author.

Alberta Health and Wellness (2000a). Private/publicHealth Services: The Alberta Approach. Unpub-lished document. Edmonton, AB.

Alberta Health and Wellness (2000b). Bill11—Alberta’s Health Care Protection Act. Ed-monton: AB. Author.

Alberta Health Planning Secretariat (1993). Starting


Page 44

Points: Recommendations for Creating a MoreAccountable and Affordable Health System. Ed-monton, AB: Alberta Health.

Alberta Medical Association (1998). Alberta MedicalAssociation Comments to Bill 30: Health Informa-tion Protection Act. Edmonton, AB: Author.

Alberta Treasury (1999). Budget ‘99: The Right Bal-ance: Fiscal and Business Plan,<www.treas.gov.ab.ca/comm/budget99/health.html>.

Alberta Treasury (2000a). Budget 2000: New Century,Bold Plans. Health and Wellness Business Plan2000-2003,<www.treas.gov.ab.ca/comm/bud2000/health.html>.

Alberta Treasury (2000b). Budget 2000: New Cen-tury, Bold Plans—Highlights and accountabilitystatement,<www.treas.gov.ab.ca/comm/bud2000/highli.html>.

Armstrong, P., and Armstrong, H. (1996). WastingAway: The Undermining of Canadian HealthCare. Toronto, ON: Oxford University Press.

Armstrong, W. (2000). The Consumer Experiencewith Cataract Surgery and Private Clinics in Al-berta: Canada’s Canary in the Mineshaft. Calgary,AB: The Alberta Chapter of Consumers Associa-tion of Canada.

Barer, M., Evans, R., Lewis, S., Rachlis, M., andStoddart, G. (2000, March 7). Decline Klein’smedicine: Alberta’s Premier has made acompletely wrong diagnosis of what ails our health system. Toronto, ON: Globe and Mail.

Bernier, Jocelyne, and Marlene Dallaire (2000). WhatPrice Have Women Paid for Health Care Reform?The Situation in Quebec, Montreal: Centred’excellence pour la santé des femmes—Consortium Université de Montréal (CESAF).

Broadbent, E. (1999). “Social democracy or liberalismin the new millennium?” In P. Russel (Ed.) TheFuture of Social Democracy: Views of Leadersfrom Around the World. (pp. 73-93) Toronto, ON:University of Toronto Press.

Brodie, J. (1996). “Canadian women, changing stateforms and public policy.” In J. Brodie (Ed.),Women and Canadian Public Policy (pp. 1-28).Toronto, ON: Harcourt Brace.

Bubel, A. and Spitzer, D. (1996). DocumentingWomen’s Stories. The Impact of Health Care onWomen’s Health. Edmonton, AB: Prepared for theEdmonton Women’s Health Network.

Canadian Institute for Health Information(1999). Na-tional Health Expenditure Trends (1975-99),<www.cihi.ca/medrls.execnhex.htm>.

Cameron, B. and Gonäs, L. (1999).”Women’s re-sponse to economic and political integration inCanada and Sweden.” In L. Briskin and M.Eliasson (Eds.). Women’s Organizing and PublicPolicy in Canada and Sweden, (pp. 87-116). Mon-treal: McGill University Press.

Casebeer, A. L. (1996). Health Policy Shift: The Pro-cess of Change. Unpublished PhD Dissertation.Calgary, AB: The University of Calgary.

Casebeer, A. L. Scott, C. M., and Hannah, K. J. (inpress) Transforming a Health Care System: Man-aging Change for Community Gain. CanadianJournal of Public Health.

Crichton, A., Hsu, D., and Tsang, S. (1990). Canada’sHealth Care System: Its Funding and Organiza-tion. Ottawa, ON: Canadian Hospital AssociationPress.

Crockatt, J. (1994). “Tories back down on controver-sial bill,” Edmonton Journal, p. A1.

CSWAC, (1999) Watering Down the Milk: WomenCoping on Alberta’s Minimum Wage. Calgary,AB: Calgary Status of Women Action Committee.

CUPE (2000). The Medicare Destruction Act,<www.cupe.ca/arvay/summary.asp>, April 5, 2000.

Dacks, G., Green, J., and Trimble, L. (1995). “RoadKill: Women in Alberta’s Drive Toward DeficitElimination.” In T. Harrison and G. Laxer (Eds).The Trojan Horse: Alberta and the Future of Canada. Montreal, PQ: Black Rose.


Page 45

Davies, R. F. (1999). “Waiting Lists for Health Care:A Necessary Evil?,” Canadian Medical Associa-tion Journal 160(10), pp. 14691470.

Donaldson, C., and Gerard, K. Economics of HealthCare Financing: The Visible Hand. London, UK:MacMillan.

Donaldson, C., and Shiell A. (2000). The Public Pur-chase of Private Surgical Services: Will the Al-berta Proposal Lead to a “Two-Tier” Health CareSystem? Unpublished manuscript. Department ofCommunity Health Sciences, University of Cal-gary.

Energy Council of Canada. (2000a). The EnergyEconomy in Canada, <www.energy.ca/ECCIC.html>,April 9, 2000.

Energy Council of Canada. (2000b). Energy Regula-tion, <www.energy.ca/EREG.html>, April 9, 2000.

Evans. R. G. (1997). “Going for Gold: TheRedistributive Agenda Behind Market-basedHealth Care Reform, “ Journal of Health Politics,Policy and the Law, 22, 427-465.

Fuller, C. (1998). Caring for Profit: How Corpora-tions Are Taking Over Canada’s Health Care Sys-tem. Vancouver, BC: New Star Books.

Geddes, A. (2000, April 7). “Province to amend pri-vate health bill,” Edmonton Journal, p. A1.

Graham, R. (1998). “Health at risk: Poverty and na-tional health strategies.” In L. Doyal (Ed.), Womenand Health Services (pp. 22-38). Buckingham UK:Open University Press.

Government of Alberta (1994). Regional Health Au-thorities Act. Statues of Alberta, 1994, Chapter R-9.07 with amendments in force as of August 1,1996. Edmonton, AB: Author.

Government of Alberta (1997). Alberta Regulation202/97, Regional Health Authorities Act, Commu-nity Health Councils regulation. Edmonton, AB:Author.

Hadley, M. (I 993). “Healthcare cuts hurt womenmost,” AARN Newsletter, 49(l 1), p. 32.

Hamilton, S.M., Letourneau, S., Pekeles, E.,Voaklander, D., and Johnston, D.W.C. (1997).“The impact of regionalization on a surgery pro-gram in the Canadian health care system.”Archives of Surgery, 132, 605-61 1.

Harrison, T. (1995). “Making the trains run on time:Corporatism in Alberta.” In T. Harrison and G.Laxer(Eds). The Trojan Horse: Alberta and thefuture of Canada (pp.118-131). Montreal, PQ:Black Rose.

Heinrich, J. (2000). On the margins of medicare. April8, p. B1. Montreal PQ: The Gazette.

Horne, T., Donner, L., and Thurston, W.E. (1999).Invisible Women: Gender and Health Planning inManitoba and Saskatchewan and Models forProgress. Winnipeg, MB: Prairie Women’s HealthCentre of Excellence.

Janzen, B. L. (1998). Women, Gender and Health: AReview of the Recent Literature. Winnipeg, MB:Prairie Women’s Health Centre of Excellence.

Jerome-Forget, M., and Forget, C. (1996). Who is theMaster: A Blueprint for Canadian Health CareReform. Montreal PQ: Institute for Research onPublic Policy.

Johnsrude, L. (2000a, February 11). “Klein calls out‘truth squads’.” Edmonton Journal, pp. A1, A6.

Johnsrude, L. (2000b, April 11) “Government forcesvote on Bill 11.” Edmonton Journal, p. A1

Kaufert, P. (1996). Gender as a Determinant ofHealth: A Canadian Perspective. Ottawa, ON:Paper prepared for the Canada-US Women’sHealth Forum.

Kerr, D. (1995). Differential Impact of the AlbertaAdvantage. Discussion paper prepared for AlbertaAdvisory Council on Women’s Issues (AACWI).Edmonton, AB: AACWI.


Page 46

Kline, M. (1997). Blue Meanies in Alberta: “ToryTactics and the Privatization of Child Welfare.” InBoyd (Ed.), Challenging the Public/Private Di-vide: Feminism, Law and Public Policy. (Pp. 330-359). Toronto, ON: University of Toronto Press.

Legislative Assembly of Alberta (1994a). DelegatedAdministration Act. Edmonton, AB:

Legislative Assembly of Alberta (1994b). GovernmentOrganization Act. Edmonton, AB: Government ofAlberta.

Lisac, M. (1995). The Klein Revolution. Edmonton,AB: NeWest Press.

Mackie, M. (1991). Gender Relations in Canada:Further Explorations. Toronto, ON: HarcourtBrace and Company, Canada.

Mackie, R., and Seguin, R.(2000, February 4). “Health care crisis, leaders warn.” Globe and Mail, p.A4.

Marsh, J. (2000), Canadian Encyclopaedia—Year2000 Edition, Toronto, ON: McLellan and Stew-art.

McArthur, W., Ramsay, C., and Walker, M. (1996).Healthy Incentives. Vancouver, BC: Fraser Insti-tute.

McKenna, R., Hanion-Dearman, A., Yassi, A. (1999).“Practice Patterns of Women in Medicine: Impli-cations for the Medical Profession. Prairie Medi-cal Journal, 64(1), 16-19.

Mooney, G. and Salmond, G. (1994). “A Reflectionon the New Zealand Health Care Reforms.” HealthPolicy, 29, 173-182.

Morris, M., Robinson, J., Simpson, J., Galey, S.,Kirby. S., Martin, L., and Muzychka, M. (1999).The Changing Nature of Home Care and Its Im-pact on Women’s Vulnerability to Poverty. Ottawa,ON: Prepared for the Canadian Research Institutefor the Status of Women, funded by the Status ofWomen Canada’s Policy Research Fund.

National Forum on Health (1997). Canada HealthAction: Building on the Legacy. Final report of theNational Forum on Health. Ottawa, ON: HealthCanada.

Northcott, H.C. and Northcott, B.R. (1999). The 1999Survey About Health and the Health System in Alber-ta. Edmonton, AB: Conducted for Alberta Healthand Wellness through the Population ResearchLaboratory at the University of Alberta.

Noseworthy, T.W. (1999). “Reconciling the Past andShaping the Future: Health and Medicare.” Key-note address to Health Summit ‘99, Calgary, AB,February 25.

Pederson, R.(2000a, March 10). “Doctor accuses gov-ernment of clouding health care issues.” EdmontonJournal, p. A7.

Pederson, R. (2000b, April 8). “Rock wants Alberta todrop patient fees.” Edmonton Journal, pp. A1,A12.

Premier’s Commission on Future Health Care for Al-bertans (1989a). The Rainbow Report: Our Visionfor Health Vol. I-III. Edmonton, AB: The Govern-ment of Alberta.

Premier’s Commission on Future Health Care for Al-bertans (1989b). What You’ve Said—NewsletterSpecial Edition. Edmonton, AB: The Governmentof Alberta.

Provincial Health Council of Alberta (1997a). HealthCheck-up on the Journey to Health Reform: Re-port Card on the Status of Health Reform in Alberta. Edmonton, AB: Author.

Provincial Health Council of Alberta (1997b). AnnualReport to the Legislature. Edmonton, AB: Author.

Rachlis, M. (2000). A Review of the Alberta PrivateHospital Proposal. Toronto, ON: Caledon Instituteof Social Policy.


Page 47

Renouf, S.(1995). “Chipping away at Medicare:‘Rome wasn’t sacked in a day’.” In T. Harrisonand G. Laxer (Eds). The Trojan Horse: Albertaand the Future of Canada (pp. 223-238). Mon-treal, PQ: Black Rose.

Ross, B.L. and Landström, C. (1999). “NormalizationVersus Diversity: Lesbian Identity and Organizingin Sweden and Canada.” In L. Briskin and M.Eliasson (Eds.). Women’s Organizing and PublicPolicy in Canada and Sweden, (pp. 310-346).Montreal: McGill University Press.

Saunders, L.D., Bay, K., and Alibhai, A. (1998).Regionalization and hospital utilization: Alberta1991/92 to 1996/97. Report #98-0001 prepared byHealth Information Unit, Department of PublicHealth Sciences, University of Alberta.

Strong-Boag, V. (1994). “Educating Medicine, Edu-cating Women Doctors: The Canadian Experience.Annales CRMCC, 27(6), 336-339.

Taft, K., and Steward, G. (2000). Private Profit or thePublic Good: the Economics and Politics of thePrivatization of Health Care in Alberta. Edmon-ton, AB: Parkland Institute.

Teghtsoonian, K. (1997). “Who Pays for Caring forChildren? Public Policy and the Devaluation ofWomen’s Work.” In Boyd. (Ed.), Challenging thePublic/Private Divide: Feminism, Law and PublicPolicy. (pp. 113-144). Toronto, ON: University ofToronto Press.

Thurston, W. E., Scott, C. M., and Crow, B. A.(1997). Social Change, Policy Development andthe Influence on Women’s Health. Halifax, NS:Synthesis Paper f the Fifth National Health Promo-tion Research Conference, July 4-5.

Thurston, W. E., Crow, B. A., and Scott, C. M.(1998). The Role of Women’s Organizations inHealth Policy Development, Implementation andDissemination. Ottawa, ON: Health Canada.

Thurston, W. E., Wilson, D. R., Felix, R., MacKean,G., Wright, M. (1999). Health Promotion Projectsin Alberta 1993-1998: An Overview. Edmonton,AB: Alberta Health and Wellness.

Trimble, L. (1997). “Feminist Politics in the AlbertaLegislature, 1972-1994.” In J. Arscott and L.Trimble (Eds.). In the Presence of Women: Repre-sentation in Canadian Governments. Toronto, ON:Harcourt Brace Canada.

United Kingdom Department of Health (1998). Inde-pendent Inquiry into Inequalities in Health Report.London, UK: The Stationary Office.

United Nurses of Alberta (1999). UNA Stat(Newsletter), July, pp. 3-7.

Valentine, P. (1999). Annual report of the AuditorGeneral of Alberta—1998-99. Edmonton, AB:Office of the Auditor General.

Webb, R., Opdahl, M. (1996). “Breast and Pelvic Ex-aminations: Easing Women’s Discomfort.” Cana-dian Family Physician, 42, 54-58.

Willson, K, and Howard, J. (2000). Missing Links:The Effects of Health Care Privatization onWomen in Manitoba and Saskatchewan. In press,Winnipeg, MN: Prairie Women’s Health Centre ofExcellence.

Wilson, D. M.(1995). The Canadian Health Care Sys-tem. Edmonton, AB: Donna M. Wilson.

Wilson, D. (2000a). Regional Health Planning andDelivery in Alberta: A Basic Cost-Benefit Analysisin Response to a Health System Performance Is-sue. Unpublished manuscript presented to theStanding Policy Committee on Health and SafeCommunities. Edmonton, AB: Faculty of Nursing,University of Alberta.

Wilson, D. (2000b). “Bill 11—A 10 point critique.”Email communication, March 15.