Contenu du sommaire : De l'utopie au réel : la santé en débat au Québec

Marc Renaud: Quebec on debate, stakes and perspectives in the field of health and social services. As in other developed countries, there is an on-going debate in Quebec as to what are the best ways to manage the financing, the production and distribution of social and health services. Since time has corne for rationing of resources, what is at stake is to invent such modalities that allow for equity and effectiveness. It was the mandate of the Inquiry Commission on health and social services (the Rochon Commission) to propose new ways of allocating resources in order to improve the health status of everyone. The present article deals with the issues the Commission had to address, and the recommendations that were made. Three philosophies of action can be identified in the propositions that were made: a strengthening of the Welfare State, a reinforcement of central power through the rationalization and bureaucratization of information systems and the enhancement of regional communities.

Jacques Godbout: Giving one's opinion: the Rochon Commission and participation. According to the Rochon Commission, what should be the role of the population in delivering health care and social services? The Commission gives two different answers to that question. In principle, the population is of fundamental importance. In the Commission's words, the population must be "at the center of the System". But in reality, clients and citizens seem much more to be located at the periphery of a system founded on expertise and technology; a System wheie citizens are ieduced to "giving their opinion". They are invited to participate in an organisation from which they are excluded, being reduced to the environment who gives feedback.

Jocelyne Lamoureux, Frédéric Lesemann: The link between public social services and community - based services in Quebec. The idea of a stronger link between public social services and community resources is central to the solutions proposed by social planers, in order to face the incrcasing costs of health and welfare services. A research on the characteristics of interface between these two types of resources reveals that : - community resources are mainly defined by public services in a dependent complementary relationship that doesn't respect their identity; - however, thanks to isolated interveners, despite agencies' control, interfaces which respect community autonomy exist sometimes; - community resources appear to be fundamentally different according to their status and objectives, inserted in a logic of solidarity and shared identities. They, however, demand recognition as resources of public interest without being required to assimilate to the entire public network. To a subsidiary complementarity they oppose equal partnership and autonomy.

Sylvie Jutras, Louise Guy on, Marc Renaud, Renée Dandurand, Pierre Bouchard: How do people from Quebec cope with health and social problem? A challenge to human sciences. The Quebec Inquiry Commission in Health and Social Services asked our research team to describe the endeavours of the Quebecers to face their health and social problems. This paper presents the conceptualization of the problem which has been looked at by a survey (n = 2 114). Besides a survey conducted amongst the gênerai population, three specific sub-groups have been studied, each representing one of the three levels of problems examined by the Commission: suffering from chronical back pain (health problem), being an informal caregiver to an elderly parent (social and health problem), and holding responsibilities as a single-head family parent (social problem). The paper presents the major results for each of the three situations. To conclude, solutions now available are discussed in a future perspective.

Gilles Beausoleil: The welfare state, and the financing of social and health services. Public expenses for health and social services are submitted to macro-economic arbitrations between transfer expenses and the funding of collective goods and services. In Canada and Quebec, during the 80s, priority has been given to the funding of social programs, which have induced a malfunctioning of the market labor and have generated inequities. The author also argues that under tight financial constraint, it is socially preferable to favor the funding of social services and goods versus health services, by transferring the burden of health expenditures on the final user.

André-Pierre Contandriopoulos, Anne Lemay, Geneviève Tessier, François Champagne: Financing schemes and cost-control of health care: the case of Quebec. Since the introduction in Quebec in 1971 of a public and universal health insurance System financed through budgetary allocation mechanisms, per capita health expenditures have risen at the same rate than the collective wealth. We fîrst describe how different strategies have been used to achieve this control on hospital and medical expenditures. We then argue that the financing mechanisms which have been used for almost 20 years will no longer be suffîcient in the coming years to maintain the control on expenditures in a system geared towards equitable and comprehensive access as in Quebec.

Clermont Begin: The sinuous path of decentralization in the Quebec health and social services System. Based on the analysis of the budgetary process, this article discusses the case of power distribution within the Quebec health and social services System. After a brief presentation of the financial and organizational public structure of that System, the paper describes and analyses the dynamics of its resource allocation process and emphasizes its highly centralized nature, despite the ministry's initiatives to transfer throughout the last two decades some of its responsibilities to the regional level. The Commission of inquiry into health and social services (the Rochon Commission) appointed by the Quebec Government has proposed a major step towards political decentralization by a per capita financing with regional marginal taxation power and the creation of regional boards leaded by elected population representatives responsible for the managing of the regional health and social services System. The ministerial response to these proposais is somewhat ambivalent. While the ministry accepts many of the commission's recommendations such as the creation of regional boards, the principles of regional financing, etc. some other important Commission's ideas devoted to increase regional financial and political accountability were abandoned. This casts some doubt on the success probabilities of the change initiative being actually undertaken.