MISSING LINKS: the Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

CENTRE OF EXCELLENCE

RESEARCHP POLICYP COMMUNITY

Administrative Centre: Regina Site: Saskatoon Site:

Prairie Women’s Health Prairie Women’s Health Prairie Women’s Health Centre of Excellence Centre of Excellence Centre of Excellence The University of Winnipeg University of Regina Extension University of Saskatchewan 515 Portage Avenue Regina, SK S4S 0A2 Saskatoon, SK S7N 5E5 Winnipeg, MB R3B 2E9 Telephone: (306) 585-5727 Telephone: (306) 966-8658 Telephone: (204) 786-9048 Fax: (306) 585-5825 Fax: (306) 966-7920 Fax: (204) 774-4134 E-mail: [email protected] E-mail: [email protected] E-mail: [email protected] WEBSITE: www.pwhce.ca

The research and publication of this study were funded by 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 the PWHCE or the official policy of Health Canada.

MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Kay Willson and Jennifer Howard

ISBN 0-9684540-5-4

ORDERING INFORMATION The full text of this report will be available on the PWHCE website at www.pwhce.ca in the summer of 2000. Additional print copies are available by mailing a cheque or money order for $10.00 in Canadian funds to:

Prairie Women’s Health Centre of Excellence Room 2C11A - The University of Winnipeg 515 Portage Avenue Winnipeg, MB R3B 2E9 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Contents

Acknowledgments...... i C. PRIVATIZING THE DELIVERY OF HEALTH CARE SERVICES...... 24 Executive Summary...... ii 1. Shift of Control to For-profit Corporations . 25 a. Non-medical services ...... 25 PART 1: INTRODUCTION b. Privatization of medical services ...... 28 D. SHIFTING FROM INSTITUTIONAL TO HOME A. PRAIRIE WOMEN AND THE CHANGING HEALTH AND COMMUNITY-BASED CARE...... 30 SYSTEM...... 1 B. A DEFINITION OF HEALTH CARE 1. Home Care ...... 31 PRIVATIZATION...... 3 a. Home care in Manitoba ...... 31 C. HEALTH REFORM IN MANITOBA AND b. Home care in Saskatchewan...... 32 SASKATCHEWAN ...... 3 c. Increases in home care in Manitoba and 1. Population Health...... 7 Saskatchewan...... 34 2. Regional Governance ...... 8 d. Privatization of home care: shifting the 3. The Shift to “Community” and Home-based provision of care to for-profit providers and Care ...... 10 unpaid caregivers...... 35 D.WOMEN AND HEALTH REFORM ...... 11 e. Privatizing home care: transfer of costs to PART 2: PRIVATIZATION OF HEALTH CARE IN individuals...... 38 MANITOBA AND SASKATCHEWAN, 1987-1999 2. Long-term Care...... 39 3. Mental Health Services...... 41 A. CUTBACKS IN PUBLIC FUNDING FOR HEALTH AND SOCIAL PROGRAMS...... 16 PART 3: IMPACTS OF PRIVATIZATION ON B. PRIVATIZING THE COSTS OF HEALTH CARE . 18 WOMEN 1. Increases in Drug Plan Deductibles and Co-payments ...... 19 A. WOMEN’S EMPLOYMENT IN THE HEALTH CARE 2. De-listing or Reducing Coverage of Health SYSTEM...... 43 Services...... 20 a. Elimination of children’s dental health B. JOB LOSSES FOR WOMEN IN THE HEALTH programs ...... 20 SECTOR...... 43 b. Midwifery: who will pay? ...... 21 C. WORKING CONDITIONS FOR WOMEN IN THE c. De-listing eye exams in Manitoba ...... 22 HEALTH SECTOR ...... 45 d. Complementary therapies...... 22 D.IMPACT ON INFORMAL CAREGIVERS ...... 48 3. Health Services Transferred to Private, E. IMPACT ON WOMEN AS CARE RECEIVERS . . 54 For-profit Companies ...... 23 F. SUMMARY OF IMPACT ON WOMEN...... 58 PART 4: CONCLUSION

A. IMPACT OF WOMEN: MISSING LINKS ...... 60 3. Public Provision/Private Provision...... 65 B. WOMEN IN ACTION: RESPONDING TO 4. Institutional Care/Home and Community HEALTH REFORM ...... 61 Care...... 66 C. FUTURE DIRECTIONS FOR RESEARCH ON 5. Public Sector Cost Control Strategies Which Mirror Private Sector Management Practices . . 66 WOMEN AND HEALTH REFORM...... 63 D.POLICY IS ABOUT MAKING CHOICES ...... 67 1. Public/Private Responsibility for Health.... 65 2. Privatization of Health Care Costs...... 65 References...... 68 Acknowledgements

We would like to express our sincere apprecia- We appreciate the assistance and helpful advice tion to Valda Dohlen, our former colleague at provided to us by our colleagues at the Prairie the Prairie Women's Health Centre of Excel- Women's Health Centre of Excellence, particu- lence, whose earlier research and work on pri- larly Linda DuBick and Sharon Jeanson. vatization in Saskatchewan was an important source of information for this report. Finally, we would like to thank the Women's Health Bureau, Health Canada, for providing We also thank Pat Armstrong and all the mem- information, encouragement and financial sup- bers of the National Coordinating Group on port. Women and Health Care Reform for providing a stimulating collaborative environment in which Kay Willson we could explore these issues together. Saskatoon Program Coordinator Prairie Women’s Health Centre of Excellence University of Saskatchewan 107 Wiggins Road Saskatoon SK S7N 5E5 P:(306) 966-8658 F:(306) 966-7920 E: [email protected]

Jennifer Howard Former Manitoba Program Coordinator Prairie Women’s Health Centre of Excellence E: [email protected].

i MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Executive Summary

During the past decade, the governments of P privatizing the delivery of health care ser- Manitoba and Saskatchewan, like those in other vices by shifting care from public institutions provinces, have introduced major changes to the to community-based organizations and pri- health care system. This process of health care vate households reform and restructuring has been driven, in P privatizing carework from public sector part, by federal and provincial policies to limit health care workers to unpaid caregivers the role of the state and control public expendi- P privatizing management practices within the tures on health care. Health care reform has also health system, by adopting the management strategies of private sector businesses. taken place within the context of a public dis- course on the determinants of health, which rec- Historically, prairie women’s organizations ognizes that health is influenced by social, eco- played an important role in the development of a nomic, and environmental conditions, not sim- publicly-funded, publicly-administered health ply by the delivery of health care services. care system in Canada. Women, to a greater extent than men, utilize the health care system to Several of the reforms in the health care system access services for themselves and other family can be understood as a renegotiation of the members. Women are the majority of workers in boundaries between public and private responsi- several health care occupations, and women pro- bility for health. The privatization of health care vide most of the unpaid, informal health care refers to several different policy directions within the home. Women earn less than men, are which limit the role of the public sector and de- more likely to live in poverty, and are less likely fine health care as a private responsibility. The to have private health insurance. privatization of health care includes: Privatization in the health care system can be expected to have significant impacts on women P privatizing the costs of health care by shift- as users of health services, as health care working the burden of payment to individuals ers, as informal caregivers, and as citizens en- P privatizing the delivery of health services by gaged in public debates over the future of the expanding opportunities for private, for- health system. Women in varying circum- profit health service providers stances, with access to different resources, will

ii MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan be affected by these changes in different ways. Health care in Manitoba and Saskatchewan has The purpose of this paper is to provide an over- also been privatized in the sense that carework view of some of the forms of health care privat- has been transferred from institutions to private ization which have taken place in Manitoba and households. Home care services have increased Saskatchewan in recent years, and to begin to and now include a greater proportion of acute identify some of the impacts of those changes on care patients. The number of institutional beds various groups of women. in both hospitals and nursing homes has declined. The average length of hospital stays has The vast majority of health services and pro- also been reduced. grams in Manitoba and Saskatchewan are provided as publicly-insured services, without addi- There have been very few studies of the impacts tional fees charged to patients. However, many of these changes on women, despite the fact that people pay privately for prescription drugs, den- women are the majority of those who provide tal care, optometric services, complementary bedside care, either as paid health care workers, medicines, treatments by non-physicians, long- or unpaid informal caregivers. Among the stud- term care, and some home care services. Since ies surveyed, several important impacts on fe- 1990, public expenditures as a proportion of male health care workers were identified: loss of total health spending have declined and private secure, well-paid, public sector jobs, increased health expenditures have risen substantially. workloads, stress, physical and emotional strain, There have been significant changes to provin- financial losses, social isolation, loss of control, cial prescription drug plans and the provincial and working conditions which make it difficult public health insurance plans have de-listed or to provide quality care. excluded several important health services. The shift from institutional to community-based care The reorganization of heath services and the has also resulted in a transfer of costs to the in- transfer of heath care costs to the individual may dividual, as services, provided at public expense have affected women’s access to services and to hospitalized patients, are no longer covered the quality of care they receive, yet very little is for outpatients. Private health insurance pro- known about the impacts of privatization on grams have expanded to fill the gaps in public women as users of health services. coverage, but private insurance is not accessible to all. The shift from institutional to community and home care has created new demands on informal In addition to the costs of health services, the caregivers. The studies which centralize the ex- delivery of health services has been privatized in periences of caregivers point to the need to de- a number of ways, although the patterns vary velop policies which will promote the well-be- somewhat in the two provinces. Examples of ing of care providers and enable them to deliver privatization include the elimination of the pub- a high quality of care. licly delivered school-based dental programs, the contracting out of food and cleaning services The impact of health care reform on women has in hospitals to private, for-profit companies, the not received the attention it deserves from the use of private, for-profit medical laboratories, research community, although some women the expansion of private personal care homes, have been voicing their concerns about the ad- the privatization of home care services, and the verse effects these changes have had on their expansion of private heath clinics. These forms lives and their health. This situation points to of privatization have, at times, been encouraged the need for a more thorough assessment of the by government policy and, at times, been sub- impacts of health care privatization and other jected to government regulation. aspects of health care reform on women.

iii MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

PART 1 INTRODUCTION

A. PRAIRIE WOMEN AND THE Recognizing the effects of poverty and inequal- ity on the well-being of people and communi- CHANGING HEALTH SYSTEM ties, many also campaigned for a radical redis- tribution of wealth and a greater voice in Prairie women’s organizations played an impor- decision-making.1 tant role in the historical development of a publicly-funded, publicly-administered health In 1947, the CCF introduced a public program care system in Canada. Saskatchewan is known of universal hospitalization insurance for resi- as the “birthplace of Medicare.” Former Sas- dents of Saskatchewan. Manitoba brought in its katchewan Premier Tommy Douglas is often first universal hospital insurance on July 1, credited as one of the “fathers of Medicare.” 1958, with the support of the federal govern- Though less well-known, prairie women like ment. In 1962, the Saskatchewan NDP intro- Violet McNaughton, Sophia Dixon, Louise duced The Medical Care Insurance Act, provid- Lucas, and Beatrice Trew could well be identi- ing universal public health insurance for physi- fied as “mothers of Medicare.” Years before the cians’ services. In 1969, Manitoba joined the “birth” of Medicare, organizations of rural federal government and other provinces in women persistently campaigned for a publicly- adopting Medicare. funded, locally-controlled system which would ensure that medical assistance be available to Throughout Canada, access to publicly-funded all. They raised public awareness and built alli- physicians’ services, hospital services, and some ances which encouraged prairie farm organiza- other health care services is now widely actions, the Canadian Commonwealth Federation cepted as a basic human right. The extent and (CCF), and eventually the Saskatchewan New specific nature of public responsibility for Democratic Party (NDP) government to develop a publicly-funded, universal health insurance program which allocates health care services on the basis of need rather than the ability to pay. 1Georgina Taylor, “Mothers of Medicare,” Women’s History Month Presentation, Saskatoon, October 1998.

Page 1 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan health services, however, remains contested During the past decade, the governments of terrain. Not all components of a comprehensive Manitoba and Saskatchewan, like those in other health system are covered by universal public provinces, have introduced major changes to the health insurance. When Medicare was intro- health care system. This process of health care duced in Canada, public insurance for physi- reform and restructuring has been driven, in cians’ services was seen as an initial, but incom- part, by federal and provincial policies to limit plete, system of publicly-funded health benefits. the role of the state and to control public expen- According to Prime Minister Lester B. Pearson: ditures on health care and social programs. Health care reform has also been influenced by The scope of benefits should be, broadly speak- a growing awareness that population health is ing, all the services provided by physicians, both determined by social, economic, and environ- general practitioners and specialists. A complete mental conditions, not simply by the delivery of health plan would include dental treatment, prescribed drugs, and other important services, and health care services. Within this context, gov- there is nothing in the approach we propose to ernment’s role in health care and health promo- prevent these being included, from the start or tion is being redefined. While expressing sup- later. If this were the general wish. We regard port for Canada’s public system of Medicare, comprehensive physicians’ services as the initial governments have also encouraged individuals minimum.2 and non-governmental sectors of society to take more responsibility for health. As a review of It is important to distinguish between funding recent health reforms will show, the boundaries for health services, delivery of health services, between public and private responsibility for and policies and programs which promote health are changing. health. In Canada, many health services, while publicly-financed, are delivered through a mix- This paper emerged out of a national effort to ture of public and non-profit institutions, private understand the effects of recent health reforms practices and community agencies. Increasingly, on women. Representatives of the five factors other than health services, such as in- federally-funded Centres of Excellence for Women’s Health3 formed the National Coordi- come, social status, education, physical environ- nating Group on Health Care Reform and ments, and healthy child development, are being Women. As a way to understand this complex recognized as important determinants of health. subject, the Coordinating Group chose to focus This concept, called “population health,” has on health care privatization. This paper is not expanded the traditional definition of health to based on original research. Each Centre of Ex- include much more than hospitals and physi- cellence carried out a scan of privatization ini- cians’ services. Declaring a commitment to tiatives in its region, and conducted a literature population health promotion, governments have search for regional research on health care pri- identified the need to address the broad social, vatization. In particular, we searched for materi- economic, and environmental determinants of als which described the impact of privatization health.

3The British Columbia Centre of Excellence on Women’s 2Lester Pearson at the, First Ministers’ Conference in Ottawa, Health; the Prairie Women’s Health Centre of Excellence; 1965. Cited in Fiona Chin-Yee, Shifting the Goal Posts and National Networks on Environments and Women’s Health; Changing the Rules: The Privatization of the Canadian Centre d’Excellence pour la Santé des Femmes—Consortium Health Care System, M.A. thesis, Acadia University, 1997, p. Université de Montréal; and the Maritime Centre of Excel- 19. lence on Women’s Health.

Page 2 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan on women as patients, health care workers and P privatizing management practices within the unpaid caregivers. In examining current litera- health system, by adopting the management ture on health care reform in Saskatchewan and strategies of private sector businesses. Manitoba, we quickly found that there was very little research on the impact of privatization and Privatization in the health care system can occur even less on the particular impact on women. in the payment for health care services or the Thus, the paper raises as many questions as it provision of health care services. In determining answers. whether or not privatization is occurring, we examined services for a shift in terms of who This paper provides a scan of some of the ways pays for the service or who provides the service. that health care is being privatized in Manitoba We defined services and providers broadly—for and Saskatchewan, and reports on the few example, we included informal caregivers as pieces of research that demonstrate how women providers and the provision of medical supplies are affected by these changes. The greater con- as a service. tribution this paper makes, however, is to begin to lay out an agenda that will firmly place women in the picture when it comes to health C. HEALTH REFORM IN policy research and that will allow the decisions MANITOBA AND that spring from that research to serve more fully the needs of women and men. SASKATCHEWAN

While it is clear that some forms of privatization B. A DEFINITION OF HEALTH are occurring in the context of health reform in CARE PRIVATIZATION both provinces, the scale and character of privatization initiatives are mitigated by different The privatization of health care refers to several recent political histories. different policy directions which limit the role of the public sector and define health care as a From 1988 to 1999, Manitoba was governed by private responsibility. The privatization of the Progressive Conservative Party, led by Gary health care includes: Filmon. On September 21, 1999, the NDP was elected to a majority government and Gary Doer P privatizing the costs of health care by shift- became Premier. David Chomiak, the former ing the burden of payment from the state to Opposition health critic, is the current Minister individuals; of Health. Diane McGifford serves as the Minis- ter Responsible for the Status of Women, a P privatizing the delivery of health services by critic portfolio she held while in Opposition. expanding opportunities for private for-profit health service providers; Health care was a major, and perhaps deciding, P privatizing the delivery of health care ser- issue in this election. vices by shifting care from public institutions to community-based organizations and pri- In the early 1990s, the Manitoba Minister of vate households; Health committed to achieving the goals of P privatizing caregiving work from public sec- health reform without introducing user fees or tor health care workers to unpaid caregivers; compromising on “the fundamental concept of and

Page 3 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Medicare.”4 There is no reference to privatiza- Opposition health critic during the Devine era. tion in any of the health reform documents The current Associate Minister of Health is Judy authored by Manitoba Health. However, health Junor, former president of the Saskatchewan policy changes in Manitoba in the 1990s in- Union of Nurses. Joanne Crofford serves as the cluded several large-scale attempts at turning Minister Responsible for the Status of Women. over parts of the public health care system to After the provincial election in September 1999, private for-profit corporations. The provincial the NDP lacked a majority and reached an Conservative government was not ideologically agreement with the Liberals to form a coalition opposed to privatization, as can be seen by at- government. tempts to privatize parts of the Home Care Pro- gram, contract-out food services at Winnipeg The Saskatchewan NDP government presents its hospitals and enter into a contract with Elec- position as one which defends Medicare in the tronic Data Systems (EDS) and the Royal Bank face of federal cutbacks in transfer payments to of Canada to construct a Provincial Health In- the provinces. The government has expressed formation Network. explicit opposition to the privatization of health care, particularly to a two-tiered system in During the 1980s, the Progressive Conservative which some services would be accessible only government in Saskatchewan, led by Premier to those who could afford them. The govern- Grant Devine, took several steps toward redefin- ment has presented its health reforms as strate- ing the health care system in the province, in- gies designed to improve the health system and cluding the appointment of a Commission on to fulfill Tommy Douglas’s vision of a “second Directions in Health Care. The commission phase of medicare.” Opposition to privatization issued its report in 1990, but the following year is evident in several provincial policies. There the Conservatives were defeated in the provin- are no premiums charged for coverage by the cial election. The major health care privatization provincial health insurance plan. The Medicare initiatives of the Devine government were the legislation includes an explicit prohibition on elimination of the publicly-funded, publicly- extra-billing by physicians. There are no private delivered school dental program, reduced cover- surgical clinics in the province. In 1996, the age for prescription drugs, and other cutbacks in government introduced The Health Facilities public funding for health and social programs, Licensing Act which placed restrictions on the which led to widespread public protests in 1987. expansion of private health facilities, requiring them to secure a license from the province, and Since coming to power in 1991, the NDP prohibiting them from charging patients extra government, led by Premier Roy Romanow, has fees. On the other hand, private expenditures for introduced several major changes to the health health care in Saskatchewan have risen, hospi- care system. The NDP health reform agenda tals have been closed, care has been shifted was introduced in 1992 by then Minister of from institutions to private households, long- Health Louise Simard. The current Minister of term care in private personal care homes has in- Health is Pat Atkinson, a Saskatoon Member of creased, and some health sector services have the Legislative Assembly (MLA) who served as been contracted out.

In both provinces there is evidence of privatiza-

4 tion creeping into the health care system. While Manitoba Health, Quality Health for Manitobans: The there has been a great deal of public disapproval Action Plan, Winnipeg: Queen’s Printer, 1992, p. v.

Page 4 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

towards user fees and extra-billing, health care These various health policy changes were made costs are being transferred to the individual as a to meet the goals of effectiveness and effi- result of some health reforms, especially the ciency—achieving better health outcomes for shift from institutional to “community”5 care. individuals at the lowest possible fiscal cost to While not overtly identified as a privatization the province. initiative, this trend has shifted responsibility for health services out of the public sector and Health reform in Manitoba and Saskatchewan onto the shoulders of families and individuals, occurred at a time when provinces were receiv- who have, in turn, utilized private health ser- ing less federal funding for health care and so- vices to meet some of their needs. cial services. In Manitoba from 1987/88 to 1998/99, provincial government spending Starting in the early 1990s, both Manitoba and decreased by $1.1 billion.6 In the same time Saskatchewan embarked on programs of major period, federal transfer payments for health, health policy changes in response to escalating education and income assistance programs were provincial health expenditures and decreasing also radically changed. In the 1994 federal bud- federal contributions for health care and social get, the federal government introduced the Ca- services. In Manitoba, this ongoing process is nadian Health and Social Transfer (CHST)— known as “health reform” in Saskatchewan, the block funding for social programs that replaced government has shifted from a discussion of existing funding schemes such as the Estab- “health reform” to “health renewal.” Although lished Program Financing (EPF) and the Canada these processes occurred under ideologically Assistance Plan (CAP). This change in social different provincial governments, they had very program funding has been called “the worst similar goals and components: social policy initiative in more than a generation”7 because it abolished national standards P a shift to population health frameworks with and severely cut funding to the provinces for an emphasis on the determinants of health, social programs. It is estimated that this change disease prevention and health promotion, will remove $1.1 billion from social program from an emphasis on provision of health spending in Manitoba by 2002.8 In Saskatche- services and treatment of disease; wan, federal cutbacks for health, education and P a shift to regional governance of health ser- social programs were $114 million in one year vices from centralized control by provincial alone, 1996-97. Federal transfers for health were governments; and reduced by $47 million, but the Saskatchewan P a shift from institutional care to “commu- government chose to fully cover that shortfall nity” and home-based care. with new provincial funding.9 Saskatchewan has continued to maintain funding for health care,

5The term “community” is used throughout health reform 6Errol Black and Jim Silver, A Flawed Economic Experiment: documents in Manitoba and Saskatchewan, usually in the the New Political Economy of Manitoba, Winnipeg: Cana- context of shifting the responsibility for caring for sick people dian Centre for Policy Alternatives, June 1999, p. 4. from institutions to home and neighbourhood-based options. 7National Council of Welfare, The 1995 Budget and Block Using the term “community” to describe who has responsibil- Funding, Ottawa: National Council of Welfare, 1995. ity for this caring work is misleading, since it is often women, 8Black and Silver, p. 13. in low-paid and unpaid positions, who carry the load. 9Saskatchewan Budget Address, Minister of Finance, 1996.

Page 5 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

but it has also made a commitment to deliver In 1992, Manitoba Health published Quality balanced budgets over the past six years. Con- Health for Manitobans: The Action Plan, a doc- trolling public expenditures for health has been ument that set out the goals and philosophy of a priority and shifting to population health was health reform—a strategy that would come to seen as an opportunity to cut health care costs. define health policy, planning and delivery in Manitoba in the 1990s. This document set out a In 1992, the Saskatchewan NDP government, series of goals for health reform, reached as a under Romanow’s leadership, embarked on a result of public consultations: process of health reform outlined in A Saskatch- ewan Vision for Health: A Framework for P to improve general health status for all Change. The problems with the health system, Manitobans; according to the government, were an overem- P to reduce inequalities in health status; phasis on treatment of disease with inadequate resources devoted to health promotion, an over- P to establish public policy which promotes emphasis on institutional care, a lack of doctors health; in rural areas, fragmented service delivery gov- P to foster behaviour which promotes health; erned by too many separate boards, and escalat- P to foster environments which promote ing health costs in a time of fiscal crisis. Noting health; that 60% of the provincial health budget was P to provide appropriate, effective and efficient allocated to hospitals and long-term care institu- health services; tions, the government embarked on a strategy of P to develop mechanisms to assess and moni- “streamlining institutional delivery systems.” tor quality of care, utilization and cost-effec- The government’s aim was to decrease reliance tiveness; on the health care system and to “encourage and P to foster responsiveness and flexibility in the enable people to take more responsibility for health care delivery system; their own health.”10 They suggested that the fee- P to promote reasonable public expectations of for-service payment system was contributing to an overutilization of health care services. They health care; and identified several “issues that have not been P to promote delivery of alternative and less 13 adequately addressed, such as family violence, expensive services. poverty, unintended teenage pregnancies, drug and alcohol abuse, and a lack of sensitivity to One of the primary motivating factors for health cultural differences.”11 The implication was that reform in Manitoba was the rising cost of health by freeing up health resources from institutional services and the uncertain relation of these costs care, these other health needs could be to health outcomes for Manitobans. To address addressed. They claimed that health reform these concerns, The Action Plan sets out a series would seek to “eliminate inequities in the health of actions: system by responding to the needs of women, families, the elderly, persons with low incomes, P develop and strengthen appropriate and others with special health needs” and that health reform would “make the health system community-oriented alternative services; more effective and efficient.”12 P develop a new role for community health centres; P restructure the hospital system; 10Saskatchewan Health, A Saskatchewan Vision for Health: A Framework for Change, 1992, p. 10. 11Ibid., p. 9. 13Manitoba Health, Quality Health for Manitobans: The 12Ibid., p. 11. Action Plan, 1992, p. 2.

Page 6 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

P enhance public education/patient empower- P to change our thinking about health and to ment; consider the broad determinants of health; P implement health human resource plans and P to provide equal opportunity for achieving resource allocation plans; health for all Saskatchewan people and com- P reform systemic cost drivers; munities; P implement technology assessment and man- P to foster healthy social environments for agement; individuals, families and communities; P develop provincial health information strat- P to preserve and promote clean, safe physical egy; and environments which support health; P evaluate the restructured system.14 P to place more emphasis on health promotion and illness avoidance; and 1. POPULATION HEALTH P to improve health and create a healthier society through the cooperation and shared re- At the time health reform and renewal were sponsibility of all members of society.15 being introduced, health policy-makers in both provinces had realized that the provision of Manitoba and Saskatchewan health reform doc- health services did not necessarily, in and of uments encourage the adoption of a population itself, result in a healthier population. Determi- health philosophy that recognizes several deter- nants such as income, education, environmental minants of health: income and social status, conditions, working conditions and social sup- education, employment and working conditions, port networks had a great impact on an individ- personal health practices and coping skills, biol- ual’s capacity to make healthy choices. This led ogy and genetic endowment, child development, to an adoption of a population health philosophy social support networks, physical environment in both provinces that essentially stated that the and health services.16 Recently Health Canada way to enhance the health of citizens was not has added gender, culture and social environ- only by opening hospitals and installing new ments to its of the determinants of health. While technology like MRI machines. Ensuring that these additions have not been thoroughly incor- people had access to education, strong networks porated into Saskatchewan and Manitoba Health of family and friends, work that was safe and documents, there are some indications that gen- provided a decent income were also key ingredi- der has occasionally been recognized as a deter- ents in creating a healthier population. minant of health. In 1992, Saskatchewan Health recognized that “the state of people’s health is In 1994, the Saskatchewan Provincial Health influenced by age, income, education, gender, Council issued its report, Population Health race and geography.”17 In 1999, Manitoba Goals for Saskatchewan: A Framework for Im- Health announced the formation of a Women’s proved Health for All. Defining health as “a dynamic process involving the harmony of physical, mental, emotional, social and spiritual 15Saskatchewan Provincial Health Council, Population well-being,” the council set forth the following Health Goals for Saskatchewan, 1994. health goals for the province: 16Manitoba Health, A Planning Framework to Promote, Preserve and Protect the Health of Manitobans, Winnipeg: Queen’s Printer, 1996, p. 4, and Saskatchewan Health. A Population Health Promotion Framework for Saskatchewan Health Districts, 1999, pp. 11-12. 14Ibid., p. 19. 17Saskatchewan Health, Annual Report, 1991-92, p. iii.

Page 7 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Health Unit within the department. In 1999, 2. REGIONAL GOVERNANCE Saskatchewan Health’s Population Health Pro- motion Model: A Resource Binder was revised In both Saskatchewan and Manitoba, one of the to include a section on gender as a health deter- major health reform initiatives to transform the minant.18 provincial health care system has been the inte- gration of health services under the jurisdiction Strategies to promote population health include of newly-created regional governance bodies, a focus on “wellness” rather than illness and a known as health districts in Saskatchewan and recognition that action to promote health could Regional Health Authorities (RHAs) in Mani- include setting health goals, changing individual toba. While these regional governance struc- behaviours, taking community action, changing tures have similar responsibilities in both prov- public policies, and building supportive envi- inces, they differ most prominently by the size ronments, as well as improving health care ser- of region they serve, the method of selection of vices. Provincial governments promised a com- board members and structural differences be- mitment to “healthy public policy” which would tween rural and urban regions. ensure that “every major action and policy of government will be evaluated in terms of its In 1993, Saskatchewan passed The Health Dis- implications for...health.”19 tricts Act which laid out the authority and responsibilities of the new districts. By the end of In describing proposed changes in Manitoba, A that year, the southern portion of the province Planning Framework set out the following re- was divided into 30 health districts and govern- quired shifts in the health care system: ing boards were established. In 1995, most Sas- katchewan Health community-based programs P from a focus on health services to a focus on were transferred to the health districts and the broad determinants of health; first elections for district health boards were P from inequity of health to equity of health; held. In 1996, two health districts were estab- P from the responsibility of Manitoba Health lished in northern Saskatchewan and the re- to an intersectoral approach; gional restructuring phase of health reform was P from illness care to health system; nearly complete.21 Saskatchewan Health contin- P from reliance on government to partnership ues to play a role in defining the overall frame- with the community; work for health care in the province, but many P from short-term action to investment in pre- decisions about health services are now made at vention and promotion; and the health district level. Health services, except P from service provider-driven to a focus on for the Athabasca Basin, are now planned and health outcomes and research-based evi- delivered by the districts, each governed by a dence.20 district health board of elected and appointed members.

18Saskatchewan Health, Population Health Promotion In 1996, the Manitoba government introduced Model: A Resource Binder, 1999 revisions. The Regional Health Authorities and Conse- 19Manitoba Health, Quality Health for Manitobans: The quential Amendments Act creating ten RHAs Action Plan, 1992, p. 10. 20Manitoba Health, A Planning Framework to Promote, Preserve and Protect the Health of Manitobans, Winnipeg: Queen’s Printer, 1996, p. 7. 21Saskatchewan Health, Annual Report, 1996-97, p. 45.

Page 8 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan outside of Brandon and Winnipeg. One year nurse to provide primary health care in rural later, the government introduced legislation to areas, or establish a community development create the Brandon Regional Health Authority, team to work with local groups addressing is- as well as two health authorities in the city of sues which affect the determinants of health. It Winnipeg. The Winnipeg Hospital Authority is also within their jurisdiction to directly pro- (WHA) has authority over hospitals and the vide or contract-out some services to for-profit Winnipeg Long Term and Community Care companies, e.g., meal services, laundry and Authority (WCA) has responsibility for commu- cleaning for health care facilities. nity health clinics and other community-based care, including responsibility for home care and In Saskatchewan, district health boards, with mental health. The recently-elected NDP gov- elected and appointed members, oversee the ernment has merged the two Winnipeg health health services in their region. According to authorities as a way to cut costs and minimize Saskatchewan Health, women are well-repre- bureaucracy. These authorities are governed by sented on district health boards. “Currently there government-appointed boards. There is no pro- are 188 women (or 51%) out of 367 board mem- vision for gender equality in board bers. Appointments are chosen based on a num- appointments, nor are health care providers eli- ber of factors. They include a commitment to gible to serve on boards. Women are under-rep- serve the needs of the district, demographic and resented on these governance structures. geographic representation, awareness of district concerns and issues, record of volunteer activities and community participation, and relevant Critics of regionalization in Manitoba expressed knowledge and experience. Balanced gender concerns that RHAs would allow Manitoba representation is an important demographic Health and the Minister of Health to relinquish criteria.”22 accountability for health planning decisions, while retaining control over funding. There also Both Saskatchewan health districts and Mani- was concern regarding the appointed, as toba RHAs are responsible for service delivery, opposed to elected, nature of the RHA boards. ongoing assessment of health needs and regional An evaluation of the regionalization process has health planning and evaluation to ensure that not been conducted yet. health services meet provincial guidelines and standards. Provincial departments of health re- In both provinces, regional health bodies are tain authority over funding allocations, legisla- given some flexibility in determining the partic- tion and policy, and maintaining standards of ular combination of services to be delivered service.23 Regional health bodies are also re- within the region. The rationale for this flexibil- sponsible for ensuring that all residents have ity is the potential for regional boards to be access to a provincially-mandated set of core more responsive to local health needs. District services, however, there is a large scope of health boards receive funding from Saskatche- decision-making for regional governance struc- wan Health largely on a population-needs-based formula. The district health boards allocate funding to health service providers and facilities within the district. A district health board can, 22Sherry Miller, Saskatchewan Health, personal communica- for example, decide to expand the range of tion, November 1999. home care services offered within the district, 23Manitoba Health, A Planning Framework to Promote, decide to hire an advanced clinical practice Preserve and Protect the Health of Manitobans, Winnipeg: Queen’s Printer, 1996, p. 5.

Page 9 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

tures on the determination of the appropriate In both provinces this shift to “community” care method and site and the allocation of staff re- and responsibility resulted in bed closures and sources to deliver the insured services. funding decreases for hospitals. In Manitoba, the share of provincial health expenditures allo- 3. THE SHIFT TO “COMMUNITY” AND cated for hospitals decreased from 44% of the HOME-BASED CARE health budget in 1977 to 41% in 1987 to 35% in 1996.27 Between 1992 and 1998, 1,317 acute The costs of hospitalization account for a major care hospital beds were closed in Manitoba, portion of provincial health budgets. As govern- reducing the ratio of acute care beds from 28 ments of all political stripes have focused on 4.8:1,000 persons to 3.6:1000 persons. As part reducing deficits, the reduction in hospital ser- of its plan to fulfill its election promise to “end vices has been seen as an important strategy for hallway medicine” ( a reference to the over- controlling public expenditures. In Manitoba crowding of Winnipeg emergency rooms that and Saskatchewan, shifting care out of institu- led to the use of hospital hallways to house pations into the “community” was also a key com- tients), the newly elected NDP government in ponent of health reform, as outlined in provin- Manitoba recently announced a plan to open cial government documents detailing health 138 acute care beds in the province.29 reform strategies. During the 1980s, the Saskatchewan Progressive In A Planning Framework, Manitoba Health de- Conservative government pursued an active scribes the need for a shift “from reliance on program of hospital and nursing home construc- government to partnership with the community.” tion. While the number of institutional beds Population Health Goals for Saskatchewan: A increased, operating budgets were tightened, Framework for Improved Health for All envi- staffing levels were cut, and concerns were sioned the improvement of health and the cre- raised that the quality of care provided in insti- ation of a healthier society through “the cooper- tutions was being undermined. Under the NDP ation and shared responsibility of all members health reforms, 50 hospitals throughout Sas- of society.”24 katchewan were closed or converted into community health centres. Between 1991/92 and Quality Health for Manitobans: The Action 1994/95, 1,200 hospital beds were removed Plan, includes the following as goals of health from the health system in the province. Between reform: “to promote reasonable public expecta- 1991/92 and 1996/97, funding for hospitals in tions of health care...[and] to promote delivery Saskatchewan was reduced by $44 million, or of alternative and less expensive services.”25 from 37% to 35% of the total health budget.30 Among the strategies required to achieve these Part of the rationale for reducing hospital beds goals are [to] “develop and strengthen appropriate community-oriented alternative ser-

vices...restructure the hospital system...[and] 27 reform systemic cost drivers.”26 Canadian Institute for Health Information (CIHI), “Mani- toba Health Expenditures,” http://www.cihi.ca/facts/manhe. html 28Manitoba Health, Annual Report 1992/93 and Annual 24Ibid., p. 7. Report 1997/98, Manitoba Health, 1993, 1998. 25Manitoba Health, Quality Health for Manitobans: The 29Manitoba Health News Release, “Five point plan Action Plan, Winnipeg: Queen’s Printer, 1992, p. 2. announced to end hallway medicine,” November 22, 1999. 26Ibid., p. 19. 30Saskatchewan Health, Annual Report, 1996-97, p. 30.

Page 10 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan was the argument that dollars saved could be Health reforms such as the shift to “community” redirected to more appropriate home and care have been founded upon certain assump- community-based care. tions about the caregiving responsibilities of families, and particularly women. These In the 1992 document, Quality Health for assumptions and the values they reflect need to Manitobans—The Action Plan, Manitoba Health be examined more closely. As support for outlines its goal to “shift more of our services institutional care has declined, public resources from high cost institutional settings to lower for home care may be increasingly focused on cost and more appropriate prevention, support medical procedures and nursing care. The provi- and home care services to help people avoid sion of social, emotional and practical support illness and delay or reduce their need for institu- for independent living, while recognized as important determinants of health, continues to be tional care.”31 defined as a private responsibility. A 1995 paper produced by the Manitoba Centre for Health Policy and Evaluation (MCHPE) and D. WOMEN AND HEALTH published in the Canadian Medical Association REFORM Journal found that medical and surgical patients in four treatment categories (prostatectomy, Women, to a greater extent than men, utilize the hysterectomy, heart attack and bronchi- health care system to access services for them- tis/asthma) were consistently being discharged selves and other family members. Women are from hospital more quickly.32 A subsequent the majority of workers in several health care paper published bythe MCHPE reported that occupations, such as nursing, home care, and between 1992 and 1998, almost one-quarter of food and laundry services. Women provide most acute care beds in Winnipeg were closed. This of the unpaid, informal health care within the study concludes that there were no negative home. Women earn less than men, are more impacts on patients’ access to hospitals, quality likely to live in poverty, and are less likely to of care provided in hospital or the overall health have private health insurance. status of Winnipeggers. However, the study Privatization in the health care system can be does not examine the issue of who provided care expected to have significant impact on women to patients who were discharged early or under- as users of health services, as health care went surgery as outpatients. The study did not workers, as informal caregivers, and as citizens assess the impact of early discharge and bed 33 engaged in public debates over the future of the closures on health care workers. health system. Women in varying circumstances, with access to different resources, will be affected by these changes in different ways. 31Manitoba Health, Quality Health for Manitobans—The Ac- The experiences and realities of women are tion Plan, Winnipeg: Manitoba Queen’s Printer, 1992, p. 16. 32 often missing in current health policy research. Lesley Graff Harrison, Noralou P. Roos, and Marni Brownell, The question of differential impact of health summary by R.J. Currie, “Discharging Patients Earlier From policy changes on women’s lives is rarely Hospital: Does it adversely affect quality of care?” Winnipeg: Manitoba Centre for Health Policy and Evaluation, 1995, http:// asked, and almost never answered. The diverse www.umanitoba.ca/centres/mchpe/readmit. impacts f these changes on women’s daily lives htm do not make their way into the mainstream dis- 33Marni D. Brownwell, Noralou Roos, and Charles Burchill, courses of health research, planning and Monitoring the Winnipeg Hospital System 1990/91- decision-making. 1996/97, Winnipeg: Centre for Health Policy and Evaluation, 1999.

Page 11 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

It appears that neither Manitoba nor Saskatche- The recently-established Women’s Health Unit wan governments have used gender analysis within Manitoba Health may provide a responsi- tools in the health reform policy process. bility centre for gender analysis. However, ana- Changes to health policy have lysing health reform through a not been examined for the ways they will affect men and women gender lens has been largely differently due to gender roles. WHAT IS GENDER left up to non-government org- Both provincial departments of ANALYSIS? anizations such as the Manitoba- health consider women’s health based Women and Health Re- as a priority area; however, "...a process that form Working Group, a coalition women’s health initiatives tend assesses the differential of provincial women’s organi- to be defined as a fairly narrow zations. In its gender analysis range of programs including such impact of proposed things as reproductive health, and/or existing policies, of Manitoba health reforms, it breast cancer screening, programs and legislation identified the scarcity of female domestic violence programs, and on women and men. It appointments to RHA boards, services for persons with eating compares how and why lack of gender-sensitive plan- disorders. women and men are ning, and the absence of infor- affected by policy issues. mation regarding the health While the Saskatchewan reform process as key con- Women’s Secretariat has pro- It makes it possible for 35 moted the use of gender analysis policy to be undertaken cerns. As well, the Working Group recognized that the shift in public policy development, with an appreciation of to early discharge and com- there is little evidence of gender gender differences, of analysis in the framework munity care means that women the nature of documents which laid the foun- will take on more of the burden dation for health reform. In re- relationships between for providing care at the same sponse to our inquiry for docu- women and men, and time they are also losing jobs due ments pertaining to the impact of their different social to health cuts.36 privatization and health reform realities, life expectations on women, we received the and economic circum- following reply from a former The Working found that the Deputy Minister of Health: stances. It is a tool for Manitoba Core Services Agree- understanding social ment provided limited access to I am not aware of any signi processes and for respon- reproductive health services, ficant public documents on the ding with informed and such as birth control informa- questions you are raising. I equitable solutions." doubt there has been any sub- tion, abortion and delivery in a stantive research done on the woman’s home community, and questions, either. While there Adapted from Status of was lacking in woman-centred is a basis for your inquiry into Women Canada, 1998. health promotion strategies.37 It the impacts on women, [at] the recommended that the regionali- time the decisions were taken by the government, the impacts zation legislation establish women’s by gender were not a key com- health advisory committees for each ponent of the analysis...there- RHA. The Working Group also fore one now can’t readily obtain the information you need.34 35Women and Health Reform Working Group, Health Reform: Making It Work for Women, Winnipeg: Women’s Health Clinic, 1997, p. 7. 34Duane Adams, personal communication, 1999. Used with 36Ibid., p. 4. permission. 37Ibid., p. 8.

Page 12 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan recommended that “gender analysis and gender- P Gender analysis did not appear to be valued sensitive planning be incorporated into all poli- by the provincial governments which fund cies and activities undertaken with respect to the the regional health bodies. For example, al- health reform at the regional and provincial though Manitoba Health has set women’s level, especially the Community Health Needs health as one of its four priority areas, RHAs appear to have been given no background Assessment.”38 These recommendations were information about women’s health, nor any not accepted by Manitoba Health. guidance about how to specifically assess the health of the women in their communities. Community Health Needs Assessments P Neither province requires that health data be (CHNAs) are carried out by regional health disaggregated by sex, although Manitoba bodies in Manitoba and Saskatchewan. These does require that the sex of survey respon- assessments form the basis for regional health dents be recorded. (Manitoba RHAs there- plans which are submitted to the appropriate fore can report the percentage of male and provincial department of health for funding. In female respondents, but they have not re- 1999, the Prairie Women’s Health Centre of ported if and how the responses of men and women differed.) While gender analysis is Excellence published a report titled Invisible much more than simply looking at health Women that examined health assessment and data for men and women both separately and planning documents in Manitoba and Saskatche- together, the lack of availability of wan for evidence of gender-based analysis. The sex-disaggregated data makes gender analy- study also included the results of key informant sis impossible. Regional health bodies are interviews with regional health representatives. also limited, since they did not have addi- Some of the key findings of this study include: tional funds to order sex-disaggregated data from other sources (such as Statistics Can- P Among the eight Manitoba RHAs and 17 ada) for their areas, nor did either province Saskatchewan health districts participating in undertake to provide this to them. P The documents reviewed do not demonstrate the study, there was little evidence of gender an appreciation for the differing health needs analysis or gender-sensitive strategies, as of diverse groups of women, including Ab- indicated by review of needs assessment and original women, women from ethnic and health planning documents, and interviews visible minorities, lesbian women and with representatives of the participating women with disabilities. health bodies. For example, only 25% of the P While both provinces officially promote a participating regional health bodies included determinants of health approach, there is any data about gender in their needs assess- little evidence of this in the health plans re- ments. viewed for this project. Manitoba health P Regional health bodies have not recognized plans contained, on average, reference to 2.4 health determinants, while Saskatchewan the additional burden on women of providing plans included an average of only 1.5 of the informal care to family members and friends. determinants used in our framework. Health Rather, they have potentially added to this plans tend to emphasize financial reporting burden by emphasizing women’s presumed and funding requests.39 role as the gatekeepers of family health. Women’s health did not appear to be valued in its own right. 39Tammy Horne, Lissa Donner and Wilfreda E. Thurston, In- visible Women: Gender and Health Planning in Manitoba and Saskatchewan and Models for Progress, Winnipeg: Prairie Women’s Health Centre of Excellence, 1999, pp. 56- 38Ibid., p. iii. 57.

Page 13 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Changes to the health care system introduced in promoted. These policy trends may have con- Manitoba and Saskatchewan in the 1990s were tributed to an expanding privatization of health not planned by taking a gendered approach, and care services. Some of these privatization initia- their impact has not been evaluated. Both prov- tives have been overt attempts to shift control of inces were very clear at the outset of health re- parts of the health care system to for-profit, form in stating their desire to protect the funda- private corporations. Most health care privatiza- mental nature of the public, universal health tion in Manitoba and Saskatchewan has been care system fought for by Prairie women. In much less obvious, involving a shift of more Manitoba and Saskatchewan, public spending responsibility for providing and paying for on health has been restricted; provincial control health care services from the state to individu- over health care services has decreased by shift- als. These types of privatization and their im- ing responsibility to regional governance struc- pact on women have been missing links in most tures; and the transfer of patient care out of in- of the debate about current and future health stitutions and into the “community” has been care policy.

Page 14 PART PRIVATIZATION OF HEALTH CARE IN 2 MANITOBA AND SASKATCHEWAN, 1987-1999

Privatization in the health care system can occur As in the rest of Canada, most health care ser- in the payment for health care services or in the vices in Manitoba and Saskatchewan are pro- provision of health care services. In determining vided by a mixture of public and private institu- whether or not privatization is occurring, we tions, organizations and health care profession- examined services for a shift in terms of who als. There are a few examples of health care pays for the service or who provides the service. services that are provided entirely by the private We defined services and providers broadly, for sector and paid for entirely by individuals or example we included informal caregivers as private health insurance. In some instances, the providers and the provision of medical supplies responsibility for payment is shared by the indi- as a service. Table 1 illustrates this definition of vidual and the state. This process is often re- privatization, although health services rarely fit ferred to as “co-payment.” neatly into either the private or public category. TABLE 1: DEFINITION OF PRIVATIZATION When discussing “public” versus “private” health services, it is important to distinguish Private Public between the funding of health services and the Payment P Individuals P State delivery of health services. As the National Fo- P Private insurance P Public insurance rum on Health notes, “Privatization of financing plans plans is not the same as privatization of delivery.”1 Many health services are provided by private Provision P For-profit, pri- of Services vate providers and institutions or individuals, but covered by pubic institutions insurance plans. For example, most doctors in P Not-for-profit, P Not-for-profit, Manitoba and Saskatchewan operate their of- community provid- publicly-managed fices as private businesses, but many of the ser- ers and institutions providers and P Unpaid care- publicly-owned vices a patient receives at the doctor’s office are givers institutions paid for by the province. P Private sector management style and structure

1National Forum on Health, The Public and Private Financ- ing of Canada’s Health System, Ottawa: National Forum on Health, 1995, p. 2.

Page 15 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Both Manitoba and Saskatchewan have a list of A. CUTBACKS IN PUBLIC core, publicly-funded health services. There are no deductibles or premiums applied to these FUNDING FOR HEALTH services and they are offered universally. When AND SOCIAL PROGRAMS services are no longer publicly-funded and payment becomes the responsibility of the individ- During the late 1980s, the Saskatchewan Pro- ual, this process is known as “de-listing.” gressive Conservative government pursued a pro-privatization agenda, advocating cutbacks in Private health care expenditures are generally public sector jobs, greater reliance on the mar- associated with services that are not considered ket, contracting out government services, and “medically necessary” under provincial health the sale of Crown corporations. This is similar plans.2 The definition of “medically necessary” to the legislative and policy agenda forwarded differs from province to province. In Manitoba and Saskatchewan, examples of services that are by the Manitoba Progressive Conservative gov- not considered medically necessary include ernment in the 1990s. private duty nursing and cosmetic surgery, which are paid for directly by the consumer or In 1987, the Saskatchewan government through a third-party insurance plan. Examples announced a series of cutbacks in health and of other services that are partially covered under social programs. The Saskatchewan Public provincial health plans or are covered only for Health Association sponsored a research study specific groups of people, such as seniors or to examine the effects of provincial cutbacks on social assistance recipients, include chiropractic a wide array of health and social services that care, pharmaceuticals, dental care and chirop- have an impact on health. Brown4 provided an ody services. Examples of medically necessary overview of the cutbacks which effectively services include most primary health care. transferred costs to non-profit agencies, community groups, families and individuals. She noted In terms of delivery, public and private distinc- the pressures placed on non-governmental orga- tions are less clear. As Table 2 shows, many nizations caused by rising demands for services health services are delivered privately—that is, and declining government funding. She they are delivered by non-governmental organi- described an increased reliance on community zations. However, this definition obscures the fund-raising and the promotion of volunteerism regulatory role government plays in service in the provision of community services. She delivery. As the Forum discussion paper points out, “Most of Canada’s health system is regu- noted increases in user fees for persons in spe- lated by and accountable to government (mainly cial care homes or receiving home care services. provincial/territorial), even though governments She argued that reductions in health care ser- deliver relatively few services directly, and in vices, earlier discharge from hospitals, and de- fact, seem committed to getting out of direct clining community services for seniors were service delivery where feasible.”3 indirectly encouraging the growth of private sector nurses and caregivers hired by those families who could afford to pay for private care.

2Canadian Healthcare Association, Canada’s Health System under Challenge: Comprehensiveness and Core Insured Benefits in the Canadian Health System, Ottawa: Canadian Healthcare Association, 1996, p. 8. 4Brown, Carol, Profile of Reductions in Health Care in Sas- 3National Forum on Health, 1995, p. 3. katchewan, 1987.

Page 16 TABLE 2: FINANCING AND DELIVERY OF HEALTH SERVICES IN SASKATCHEWAN AND MANITOBA Service Type Financing Delivery Hospital services 100% public for medically necessary services (no user charges Public In Manitoba, some hospital permitted) Private payment for upgraded accommodation or services, such as abortions, are provided non-medically necessary services provided in hospital (these in private clinics extra charges are covered by some private insurance plans) Physician 100% public for medically necessary services (no extra-billing Private Physicians are independent and services permitted) Private payment for non-medically necessary self-regulating services In Manitoba, legislation was recently introduced to remove “tray fees”—a practice of extra-billing applied to certain medical procedures, such as cataract removal, in private facilities. However, abortions performed in private clinics are still uninsured. Dental/optometry Mostly private (insurance or out-of-pocket) Some provincial Private and self-regulating care coverage for specific groups, e.g., children, social assistance recipients and other low income. Both Manitoba and Saskatchewan have reduced publicly-funded dental programs for children. Prescription Mixed public/private Coverage varies Drugs dispensed in Private Delivery includes prescription by drugs hospitals are covered in hospital budgets. Balance is funded by physicians and dispensing by pharmacist combination of private insurance plans and out-of-pocket. Both or hospital Manitoba and Saskatchewan have public drug insurance plans—drugs are subsidized after a certain deductible limit has been reached. Non-prescription Mostly private (out-of-pocket) Private Over the counter drugs Mental health Mixed private/public In Manitoba, psychiatrist and psychologist Mixed public/private Some community services fees are covered when referred by a physician. They may also be mental health services are operated by covered by some private insurance plans. Fees for counsellors and non-profit organizations. In Saskat- social workers in private practice are generally not covered by chewan, mental health services are Manitoba Health. available to all residents through a network of over 60 mental health clinics, administered through the health districts. Services of other Mixed public/private (insurance or out-of-pocket) In Manitoba, Mixed public/private (e.g., psy- professionals payment for midwifery services will be the responsibility of the chologists, physiotherapists, chiro- state. In Saskatchewan, payment for midwifery services is the practors, midwives, private duty nurses, responsibility of the individual. traditional Aboriginal healers) Complementary Private Private (e.g., naturopaths, homeopaths, medicines practitioners of oriental medicine, traditional Aboriginal healers) Long-term care Mixed public/private Public portion covers insured health care Mixed public/private (residential) services; private portion covers room and board Home care Partial public coverage provided M i x e d pu b li c / pr ivate Informal caregivers play an important role Ambulance Partial public coverage in some provinces; special programs for Mixed public/private operators services residents of remote areas Public health Public Public programs Services to status Public Mixed public/private Federal govern- Indians and Inuit ment employees deliver some services directly Adapted from a national chart in The Public and Private Financing of Canada’s Health System by the National Forum on Health, 1995.

Page 17 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Brown reported cuts to groups engaged in advo- dents of Saskatchewan or Manitoba. In addition, cacy for persons with disabilities, persons on some health services are funded by private social assistance, and women. She concluded health insurance, out-of-pocket payments, that funding cuts were increasing inequities in worker’s compensation and public auto insur- health and that natives, youth, children, the el- ance. Our health system also relies on fund-rais- derly, the disabled, psychiatric patients, the ing, volunteers, and unpaid informal care ar- mentally handicapped and victims of abuse are rangements. In 1995, the National Forum on the losers.5 Health reported that approximately 72% of the total health expenditures in Canada were For both Manitoba and Saskatchewan, the level publicly-funded.6 In Saskatchewan and Mani- of provincial debt, the development of the Can- toba in 1995, that figure was slightly higher than ada Health and Social Transfer (CHST), the the national average at 74.8% and 74.5% re- reduction in federal transfer payments and pro- spectively.7 vincial governments’ pursuit of balanced budgets have limited government spending on so- Table 3 and Table 4 compare public and pri- cial programs. Representatives of agencies pro- vate sector health expenditures from 1990 to viding services to women have raised concerns 1998. Data on private financing of health care in about the erosion of public support for women’s Saskatchewan and Manitoba indicate a steady services in recent years, but there has been no and dramatic increase since 1990. Between systematic survey of changes in women’s ser- 1990 and 1996, private health care expenditures vices to examine the impact on women’s health. increased by 43% in Saskatchewan and 33% in Several organizations have raised concerns over Manitoba. In contrast, between 1990 and 1996, unemployment, the lack of pay equity legisla- public financing of the health system increased tion, the inadequacy of social assistance pay- by only 3.2% in Saskatchewan and 7% in Mani- ments and the continuing barriers to health toba. Moreover, total public health spending in caused by poverty. This topic cannot be dealt current dollars actually decreased three times with adequately in this paper, but is mentioned during that time period in Saskatchewan and here, to draw attention to the fact that the ero- once in Manitoba. sion of public spending for a wide array of social programs in health, education, housing, Shifting responsibility for the costs of health employment, social assistance, etc. are part of a care to individuals has not been done by bold broader pattern of privatization which is based initiatives. A form of “creeping privatization” upon reducing the role of the welfare state. has occurred as more and more health care costs have gradually been moved into the private B. PRIVATIZING THE COSTS sphere as a result of the increasing levels of co- payment or deductibles; de-listing of services; OF HEALTH CARE narrowing the definition of “medically necessary” service; and shifting acute and chronic Saskatchewan and Manitoba’s health system is care out of institutions, into the community. funded through a combination of general tax revenues and federal transfer payments. There are no health care premiums assessed to resi- 6National Forum on Health, 1995, p. 3. 7Canadian Institute for Health Information (CIHI), National Health Expenditure Trends 1975-1998, Ottawa: CIHI, 1999, 5Brown, 1987. p. 99.

Page 18 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

TABLE 3: COMPARISON OF PUBLIC AND PRIVATE TABLE 4: COMPARISON OF PUBLIC AND PRIVATE HEALTH EXPENDITURES IN MANITOBA HEALTH EXPENDITURES IN SASKATCHEWAN 1990-1998 1990-1998 Year Year Public Health Expenditures ($000) Public Health Expenditures ($000) Change from Previous Year Change from Previous Year Private Health Expenditures Health Private ($ ‘000,000) Expenditures Health Private ($ ‘000,000) Change from Previous Year Year Previous from Change Year Previous from Change Share of Health Expenditures Health Share of Expenditures Health Share of Share of Health Expenditures Health Share of Expenditures Health Share of 1990 1999.3 79.9% 11.0% 533.2 20.1% --- 1990 1810.8 79.7% 9.7% 460.1 20.3% 8.6% 1991 2059.0 78.3% 3.5% 569.9 21.7% 6.8% 1991 1844.4 79.0% 1.9% 490.8 21.0% 6.7% 1992 2106.5 78.0% 2.3% 594.8 22.0% 4.4% 1992 1831.3 77.9% (0.7)% 518.7 22.1% 5.7% 1993 2078.1 76.0% (1.3%) 656.2 24.0% 10.3% 1993 1732.3 75.3% (5.4)% 568.3 24.7% 9.6% 1994 2097.2 75.3% 0.9% 688.3 24.7% 4.9% 1994 1813.8 75.2% 4.7% 599.5 24.8% 5.5% 1995 2138.3 74.5% 2.0% 732.8 25.5% 6.5% 1995 1811.8 74.8% (0.1)% 610.0 25.2% 1.7% 1996 2149.8 73.1% 0.5% 791.7 26.9% 8.0% 1996 1868.8 74.0% 3.1% 656.9 26.0% 7.7% 1997f 2223.3 73.0% 3.4% 822.3 27.0% 3.9% 1997f 1946.5 74.1% 4.2% 681.0 25.9% 3.7% 1998f 2327.5 73.3% 4.7% 849.7 26.7% 3.3% 1998f 2035.7 74.1% 4.6% 709.9 25.9% 4.2% f = Forecasted numbers f = Forecasted numbers Source: Canadian Institute for Health Information, National Source: Canadian Institute for Health Information, National Health Expenditure Trends 1975-1998, Canadian Institutes Health Expenditure Trends 1975-1998, Canadian Institutes for Health Information, 1999, p. 91, 97. for Health Information, 1999, p. 91, 97, 99.

1. INCREASES IN DRUG PLAN Manitoba and Saskatchewan were increasing DEDUCTIBLES AND CO-PAYMENTS deductibles and co-payments of provincial drug insurance plans, federal legislation was passed The cost of prescription drugs is one of the fast- that allowed pharmaceutical companies to retain est growing health care costs. While the cost of patents on drugs for twenty years, delaying the prescription drugs remains a public responsibil- introduction of cheaper, generic drugs. This ity for some, the prescription drug costs of many legislation has led to higher drug costs. Between Saskatchewan and Manitoba residents have 1987 and 1996, the cost of prescription drugs in 8 been defined as a private financial responsibil- Canada rose 93%. ity. Both Saskatchewan and Manitoba have provincial public drug insurance plans that partially The Manitoba Pharmacare Program was cover the costs of prescription drugs for some changed from a universal deductible format to populations. A series of changes to these plans an income-based drug insurance program. In has resulted in a shift of the responsibility for payment for drugs to individuals and private health insurance plans. At the same time as 8Frances Russell, “Profit drives up health costs,” Winnipeg Free Press; December 8, 1999, p. A12.

Page 19 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

1994, the Pharmacare deductible was $129.00 to that time, they had paid $3.95 per prescrip- for families with at least one member over 65 tion. The most recent changes to the plan were years of age and $227.60 if the family had no made in 1993. At that time, semi-annual deduct- members over 65 years of age.9 In 1996, the ibles were set at $850, and the rate of co-pay- policy changed so that deductibles are currently ment was increased to 35%. According to the based on 2% of adjusted income, if income is former Deputy Minister of Health, one of the less than $15,000 and 3% of adjusted income if “biggest impacts on the individual (no break- income is more than $15,000, with a minimum down by gender of which I am currently aware) deductible of $100. An individual with an ad- had to do with changes in the qualifying rules of justed income of $20,000 would have an annual the drug plan.”11 Pharmacare deductible of $450. In order to be eligible for Pharmacare coverage, the drugs In both provinces, there are special programs must be on the provincial formulary and not which provide coverage for people with certain covered by any other provincial, federal or pri- medical conditions, palliative care patients, vate insurance program. New drugs and those people with special support circumstances, considered experimental may not always be emergency situations, and persons receiving eligible for coverage. These are often the income supplements. highest-priced drugs. In 1997-98, the Manitoba Pharmacare Program processed 5,493,647 pre- According to Saskatchewan Health, in 1996-97, scriptions and provided benefits totaling approx- the province paid an average 97.7% of prescrip- imately $60 million to 55,657 families.10 tion drug costs for over 43,584 families who were not subject to a deductible. For those who The Saskatchewan Prescription Drug Plan began were subject to a deductible and co-payment, in 1975 as a fixed co-payment scheme. Persons the province provided, on average, 8.4% of total paid a set fee per prescription and the provincial prescription costs.12 government paid for additional drug costs. In 1987, the Progressive Conservative government 2. DE-LISTING OR REDUCING PUBLIC introduced changes to the Saskatchewan Pre- COVERAGE OF HEALTH SERVICES scription Drug Plan which shifted more responsibility for payment to patients and their fami- a. Elimination of children’s dental health lies. The policy change introduced annual deductibles of $125 per family, $75 per senior programs family, and $50 per single senior. Persons were Payment for the majority of dental care in Mani- required to pay 20% of the drug costs which toba and Saskatchewan is the responsibility of exceeded the deductible. individuals and may be covered by private insurance. People receiving social assistance and In Saskatchewan in 1991, the level of co-pay- Aboriginal people who are status Indians ment was increased and residents of special care homes were made subject to deductibles. Prior

11Duane Adams, personal communication,1999. Used with 9Manitoba Health, Annual Report 1993-94, Manitoba Health, permission. 1994. 12Saskatchewan Health, Drug Plan and Extended Benefits 10Manitoba Health, Annual Report 1997-1998 www. Branch Annual Statistical Report, 1996-1997, Saskatchewan gov.mb.ca/health/ann/199798/4abcdefg.html Health, 1997.

Page 20 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

receive insured dental care benefits. Manitoba resulted in the lay-offs of 50 dental health prac- and Saskatchewan independently introduced titioners, mostly women.14 In 1993-94, 22,500 coverage for dental care for children as part of children were participating in the weekly fluo- the publicly-insured health plans. School-based ride rinse program.15 dental health programs that featured strong prevention and education components were popular Over time, financial responsibility for children’s features of the children’s dental health pro- dental care has shifted to families and private grams. dental insurance programs. Provincial governments continue to provide coverage for children In 1987, the Progressive Conservative govern- on social assistance and in other low income ment in Saskatchewan announced the elimina- families. A universal, publicly-funded, publicly- tion of the school-based dental program which delivered children’s dental program has been had begun in 1974, despite studies which indi- replaced by privatized service delivery and a cated its effectiveness. Five hundred seventy mixture of public and private payment. school-based dental clinics were closed. In one of the clearest examples of privatization of b. Midwifery: who will pay? health services in recent Saskatchewan history, the government eliminated a publicly-funded, For many years, women’s advocacy organiza- publicly-delivered service which provided basic tions in Manitoba and Saskatchewan have lob- dental care to children throughout the province. bied for the legalization of midwifery and the These services were delivered by public sector public provision of women-centered midwifery workers, most of whom were women employed services. Both provinces have recently begun as dental therapists and dental assistants. Under the processes of legalization, however, the way the new system, dentists in private practice be- these services will be paid for is different in came the main providers of dental services for each province. children. Provincial coverage for children’s dental services was discontinued for young peo- In 1994, the Saskatchewan Minister of Health ple 14 to 17 years old. established a Midwifery Advisory Committee. In 1996, the committee issued a report recom- In 1993, the Manitoba government excluded mending that the province legalize midwifery, basic coverage of dental care for children from allow home births, and provide public funding publicly-insured benefits. In 1996/97, the Week- for midwifery care. A Midwifery Implementa- ly School Fluoride Rinse Program was discon- tion Committee was established to advise on the tinued and the responsibility for dental preven- process of integrating midwifery services into tion and promotion programs was transferred to the provincial health system. In May 1999, the the RHAs as part of the Core Services man- Saskatchewan legislature passed The Midwifery date.13 According to government Opposition Act, legalizing midwifery and establishing pro- critics, the cancellation of the school dental vincial licensing and regulation of the profes- program, which offered fluoride treatment and sion. screening for cavities, saved $3 million and

14Shauna Martin, NDP Caucus Health Researcher, personal communication, March 1999. Used with permission. 13Manitoba Health, Annual Report 1997-98 www. 15Manitoba Health, Annual Report 1993-94, Manitoba gov.mb.ca/health/ann/199798/4abcdefg.html Health, 1994.

Page 21 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

However, the Saskatchewan government has ble need to the RHA Boards and administrators, made no commitment to provide public funding and, therefore, a woman’s access to midwifery for midwives’ services, although women under in Manitoba may be limited by her geographic a midwife’s care would have their hospitaliza- location. tion and diagnostic tests covered. Without public funding, women choosing a midwife would c. De-listing eye exams in Manitoba be required to pay privately for those services. According to the Midwives Association of Sas- In April 1996, regular eye examinations for katchewan, “[w]ithout government money, mid- people between 18 and 64 years of age were wifery in the province is in danger of becoming taken off the Manitoba health insured services non-existent….When the regulation of mid- list. Exceptions are made for people with med- wifery comes into practice, midwives will have ical conditions that require exams by optome- to pay for malpractice insurance, association trists. Current fees for eye exams range from fees, and clinical costs, all of which will force $45 to $90 and are often offered at locations that them to raise fees to about $2,000 per also sell eyeglasses and contact lenses. Mani- birth….Increased midwifery fees and no public toba Health saved $3 million by eliminating its funding will mean a two-tiered system where responsibility to pay for 45% of eye exams.18 only the elite will be able to choose the care of a 16 midwife.” d. Complementary therapies

In 1997, the Manitoba government introduced Complementary therapies, such as acupuncture, and unanimously passed legislation legalizing naturopathy, massage, homeopathy and herbalist midwifery in Manitoba. Proclamation of this consultation, are not currently covered in Mani- legislation has been delayed pending the cre- toba or Saskatchewan. These practitioners ation of an administrative and educational infra- charge their clients fees for their services. structure for midwives. The legislation provided for midwifery to become an autonomous profes- Chiropractic care is subsidized by Manitoba sion, governed by the College of Midwives in Health. Manitobans are allowed twelve visits Manitoba. Practicing, licensed midwives are per year to a chiropractor for adjustments only expected to be in place this year. On several and are assessed a fee for each visit. The num- occasions, the Minister of Health has stated that ber of visits allowed have been cut in recent midwifery will be an insured service in Mani- years. Treatment resulting from motor vehicle 17 toba. However, RHAs are responsible for in- accidents is covered by Manitoba Public Insur- cluding midwifery services as part of their ance Corporation (public auto insurance).19 In health plans submitted to Manitoba Health for Saskatchewan, the province provides coverage funding. The availability of midwifery services for chiropractic services, but chiropractors may in Manitoba will rely on the RHAs’ belief about charge patients additional fees. Full coverage is the need for these services. Given that research provided to persons eligible for supplemental has demonstrated that RHAs have not success- health benefits.20 fully included gender analysis in their health planning processes in the past, women’s health services, such as midwifery, may not be a visi- 18Ibid., p. 29. 19Manitoba Health Web Site - Insured Benefits www.gov. 16Jillian MacPherson, “Midwifery threatened by lack of gov- mb.ca/health/ib/oipb.html ernment support,” Saskatoon Star Phoenix, October 26, 1999. 20Health Canada, “Health System Reform in Saskatchewan,” 17Health Canada, Provincial Health System Reform in Health Reform Database: Overview by Province, 1998-99, p. Canada - Manitoba Version 3, Health Canada: 1997, p. 41. 27.

Page 22 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

3. HEALTH CARE SERVICES Regulations, which came into effect January 1, TRANSFERRED TO PRIVATE, 1999, will end the practice of facility or tray 23 FOR-PROFIT COMPANIES fees charged for some surgical procedures. This legislation has been compared to Alberta’s When most people think of health care privat- Bill 11. Opposition government critics ex- ization, they conjure up the image of for-profit pressed concerns that the legislation provides a health businesses charging patients for their framework for negotiating with private for-prof- services. In some provinces, private surgical it companies to provide medical and surgical clinics have been allowed to bill governments services, thereby opening the door for more for publicly-insured health services while charg- private health care financed by public funds. ing patients additional facility fees. Access to these services therefore is not available to all on This legislation will not end the practice of the basis of need, but is restricted to those who charging a fee for abortions provided at the can afford to pay. In 1996, the Saskatchewan Morgentaler Clinic in Winnipeg. Although abor- government introduced legislation specifically tions are included in the provinces Core Ser- designed to prevent the development of this vices Agreement (a list of services that must be kind of two-tiered health system. Under The provided without cost to users), the provincial Health Facilities Licensing Act, all private government has consistently refused to cover health facilities are required to obtain a license the costs of abortions performed outside of hos- from the provincial government and are prohib- pitals. Dr. Morgentaler launched a legal chal- ited from charging additional fees for services lenge to the province’s refusal to pay for abor- covered by Medicare. There are no private, for- profit health clinics operating in Saskatche- tions and on March 2, 1993, won his case. On wan.21 July 27, 1993, the Manitoba government passed an amendment to The Health Services Act to In 1997, there were approximately 13 private counteract the court’s decision. This amendment clinics offering surgical procedures in Mani- excludes payment for non-hospital abortions.24 toba. These clinics offered procedures such as endoscopy, abortion, eye surgery, plastic sur- In Manitoba, abortions are performed up to 14 gery and oral surgery. Physicians at these clinics weeks gestation in two hospitals in Brandon and received a fee-for-service from Manitoba Health Winnipeg. Waiting times at hospitals can be as for the procedure, and charged an additional long as six weeks, while wait times at the “tray fee” to the patient. Health Canada viewed Morgentaler Clinic are usually less than a week. this as a violation of the Canada Health Act and Abortions cost between $500 and $550 at the penalized Manitoba $49,000 per month for al- Morgentaler Clinic. This is not an extra-billing, lowing the practice of extra billing.22 as Manitoba Health does not cover the costs of 25 In 1998, the Manitoba government introduced abortions performed at Morgentaler at all. an amendment to The Health Services Act. This legislation, as well as the Surgical Facilities 23Manitoba Health News Release, “Manitoba Health to pay facility fees for all medically insured services,” December 30, 1998. 21Ibid., p. 26. 24Canadian Abortion Rights Action League (CARAL) www. 22Health Canada, Provincial Health System Reform in caral.ca/situation1.html#situation1.html#mb Canada - Manitoba Version 3, Health Canada: 1997, p. 28. 25Ibid.

Page 23 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

An often-cited criticism of private, for-profit C. PRIVATIZING THE DELIVERY medical care is that it creates a two-tier system of services. Patients who are able to pay extra OF HEALTH CARE SERVICES costs are able to avoid wait times and may receive better care than patients who are unable or Privatization of the delivery of health services in unwilling to pay privately for health care. A Manitoba and Saskatchewan has occurred in a 1998 study by the Manitoba Centre for Health piecemeal fashion by shifting control of compo- Policy and Evaluation (MCHPE) examined the nents of the health care system to for-profit, case of cataract removal surgery in Manitoba. private corporations. In Manitoba, there have Researchers compared waiting times between been three main attempts at this: the creation of private clinics offering the surgery to public the Urban Shared Services Corporation (USSC) hospitals. The researchers found that 40% of and the development of a centralized food pro- private clinic patients lived in the two lowest duction facility, managed by a private corpora- income neighbourhoods in Winnipeg, but this is tion, to supply the major Winnipeg hospitals not necessarily an indicator of personal income. and long-term care facilities; the SmartHealth In all cases the physicians’ fees were paid by initiative by Royal Bank and later Electronic Manitoba Health, but private clinics charged Data Systems (EDS) to administer an electronic patients an additional fee of between $1,000 and health and drug information network; and the $1,200. transfer of a significant portion of home care clients to the private, U.S.-based corporation, Proponents of for-profit health care argue that Olsten Health Services. In each one of these private clinics will decrease waiting times. The attempts to privatize components of the health MCHPE study researchers found that some wait care system, the provincial government publicly times may be increased because of the introduc- stated that the initiative would deliver services tion of for-profit health care. Median waiting more effectively and reduce expenditures in the times for cataract removal surgery at private health care system. However, none of these clinics were four weeks, while in public facili- large-scale privatization initiatives has yet ties wait times ranged from 10.9 to 17.9 weeks. achieved this goal. The privatization of parts of Eighty-five to ninety percent of cataract re- the home care system was abandoned after it moval procedures were performed in public was found that none of the private corporations facilities. The longest wait times were encoun- who bid on the contract could deliver the vol- tered by public facility patients of physicians ume of services at or below the current expendi- who practiced in private, as well as public facili- ture level provided to the public system. The ties. Researchers concluded that “if surgeons are SmartHealth initiative was ended in 1998 after allowed to operate in both [the private and pub- costing an estimated $34 million without lic] sectors, there is an incentive for them to achieving the main goals of the project. The encourage long waits in the public sector, [and it USSC Food Services operation is currently un- is] more likely the patient will seek private dergoing a special audit to determine if it will be 26 care.” able to provide services to the partner facilities within the forecasted cost.

26 Other forms of service delivery privatization K.C. DeCoster Carrière, Sandra Peterson, Randy Walld, have not been as obvious. Regionalized gover- Leonard MacWilliam; summary by RJ Currie, Surgical Wait- ing Times in Manitoba, Winnipeg:: Centre for Health Policy nance of the health care system in Manitoba and and Evaluation, 1998, p. 54.

Page 24 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Saskatchewan and the lack of provincial legisla- management in North America,” has cut laundry tion strengthening public delivery and provision service, maintenance and dietary staff comple- of services, such as legislation introduced in ments. In addition to staff cutbacks, both em- British Columbia,27 has allowed some regional ployees and residents report a noticeable decline health bodies to contract-out non-medical ser- in the quality of food services in the district. vices, such as food preparation and cleaning Previously homemade dishes have been re- services, to for-profit suppliers. These services placed with prepackaged or frozen meals. Ac- are the less visible parts of health care facilities, cording to Gardner, “with these changes comes although providing nutritious, appetizing food the ‘de-skilling’ of dietary staff, and quality and and a clean physical environment are key ingre- nutrition go right down the drain.”29 Local resi- dients in the recovery and long-term health of dents also note that the multinational company patients. Administrators and the public may has quickly moved to cut off local suppliers, view the privatization of these non-medical which in turn, has a detrimental effect on the services as less threatening to a universal and local economy. high-quality health care system than the privatization of medical services. In fact, a press re- A number of health districts in Saskatchewan lease announcing the formation of a non-profit have considered contracting out food and house- corporation to allow Winnipeg hospital and keeping services to private, for-profit corpora- long-term care facilities to share certain non- tions. However, members of the Canadian Un- medical services described these services as ion of Public Employees (CUPE) have mobi- “areas behind the scenes, not in direct contact lized opposition to these forms of health care with patients and their families.”28 privatization. In the Assiniboine Valley, Battle- fords, and Prince Albert Health Districts, CUPE 1. SHIFT OF CONTROL TO campaigns contributed to health board decisions FOR-PROFIT CORPORATIONS not to contract-out. The company seeking the contract, in all three cases, was Versa Foods a. Non-medical services (Aramark). Marriott Corporation has contracts to provide food services to health facilities in East Central Health District. There have been some instances of health care organizations in Saskatchewan contracting out In Manitoba, the move to privatize certain hos- services to private companies. Gardner (1998) pital service sectors came under the guise of the reports that the Swift Current Health District Urban Shared Services Corporation (USSC),30 contracted with the U.S. multinational, which was formed in 1994 as a non-profit cor- Sodexho-Marriott Services Inc., to provide poration by nine Winnipeg hospitals to pursue cleaning, kitchen, and maintenance services. consolidation of laundry and food services, bio- The company, which describes itself as “the lar- medical waste disposal and contracting, and gest provider of out-sourced food and facilities

29Gardner, 1998, p. 13. 27Section 3.3 of the British Columbia Health Authorities Act 30The USSC includes Seven Oaks General Hospital, the (Provincial Standards) states that “The minister must ensure Health Sciences Centre, Grace General Hospital, Deer Lodge that…health services in British Columbia continue to be Centre, Concordia General Hospital, Victoria General Hos- provided on a predominantly not for profit basis.” pital, Riverview Centre, St. Boniface General Hospital and 28Manitoba Government News Release, November 24, 1994. Misericordia Care Centre.

Page 25 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

purchasing and warehousing of materials. The The 34,000 square foot USSC Regional Food goals of the USSC were “to determine the po- Distribution Facility is the largest in North tential for improving efficiency, reducing dupli- America. The facility began operations in Au- cation and increasing buying power.”31 gust 1998. According to the USSC, its centralized system will result in the loss of 252 full- In 1997, the USSC signed the Shared Food Ser- time equivalent positions.35 Concerns have been vice’s Patient Food Service Agreement with raised with regards to the quality of food pre- NewCourt Capital Inc., a Toronto-based capital pared using rethermalization techniques (freez- finance firm. Other parties to this agreement ing and re-heating prepared food) and the capac- include the Winnipeg Hospital Authority (now ity of a centralized food service to respond to amalgamated with the Winnipeg Long-Term specific cultural and dietary requirements. Ini- and Community Care Authority as the Winnipeg tial media reports concerning patients’ assess- Regional Health Authority). The USSC then ment of the meals are not favourable. This is announced the construction of a central food especially true at long-term care facilities, such preparation facility to serve Winnipeg hospitals, as Deer Lodge Centre. including two long-term care facilities. USSC contracted with Versa Foods, Inc., which has During the 1999 Manitoba election, discontinu- since become Aramark Ltd., to manage the fa- ing the use of rethermalized food at long-term cility.32 In the contract, NewCourt Capital is to care facilities was a key NDP promise. The na- provide long-term financing for the construction ture of the 20-year agreement, however, means of the food preparation and distribution facility. Each hospital agrees to use and pay for this fa- that participating hospitals would have to con- cility for twenty years.33 tinue to pay $50,000 per month for the centralized food services, even if the program was 36 Centralized hospital food preparation was sup- discontinued. On December 6, 1999, the proposed to result in cost savings of $5.9 million vincial government announced it had taken over because hospital cafeterias would not be refur- control of the contract that had existed between bished, the new facility would have lower oper- USSC and NewCourt Capital. The extension of ating costs, and losses from non-patient food the central food distribution system to Health services would be reduced.34 However, costs in Sciences Centre and St. Boniface General Hos- terms of job loss for food preparation staff and pital was put on hold. The government moved costs to the local economy of not using local quickly to take over the contract when it became food suppliers were not taken into consider- known that a banking giant, CIT of New York, ation. In addition, the cost to the health of pa- had announced that it was taking over New- tients, resulting from a perceived lowered qual- Court Capital. By taking NewCourt out of the ity and taste of food, was not recognized in arrangement, the provincial government has making the decision to go forward with the ensured that approval for changes to the food agreement. distribution system will not be required from a financial institution in another country.37

31Philippe Cyrenne, Analysing Shared Service Contracts: The Case of Food Services for Winnipeg Hospitals, Canadian Centre for Policy Alternatives: June 1999, p. 1. 35Ibid., p. 3. 32Health Canada, Provincial Health System Reform in 36Doug Nairne, “NDP stuck with Tory leftovers”, Winnipeg Canada - Manitoba Version 3, Health Canada: 1997, p. 3. Free Press: December 3, 1999, p. A4. 33Cyrenne, 1999, p. 1. 37Manitoba Government News Release, “Government takes 34Ibid., p. 4. over USSC contract,” December 6, 1999.

Page 26 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

The costs of the USSC food distribution plan Royal Bank has sold 51% of the shares in continue to increase. On December 3, 1999, the SmartHealth to Electronic Data Systems Cor- Winnipeg Free Press reported that many of the poration (EDS), a Texas-based multinational costs of the new facility had been underesti- corporation that has been involved in welfare mated and that the facility would be too small to privatization in the U.S.40 realize its goal of delivering food to all of the participating hospitals. The new food system When fully implemented, the Health Informa- also required more staff than originally fore- tion Network (HIN) was supposed to link autho- casted. The provincial auditor has ordered a rized health care providers throughout the prov- special audit of the centralized food preparation ince to enable access to patient information such and delivery system in 2000.38 The existence of as immunization history, laboratory and x-ray a centralized facility has been built into the fu- test results, and current medications. During ture construction of health care facilities. There 1997/98, the HIN piloted the medication com- are new personal care homes currently under ponent of the system, the Drug Programs Infor- construction without kitchens. While the bene- mation Network (DPIN), in five hospitals.41 A fits in terms of cost savings may never material- key component of this system was the “Smart ize, the legacy of the USSC Shared Food Ser- Card,” a plastic card with a magnetic stripe en- vices Agreement will be with Manitoba citizens coding patients’ health information and history. for many years. The introduction of this form of information technology raised many concerns regarding Another example of shifting non-medical health privacy and security of health data. services in Manitoba to for-profit corporations is When the contract was announced, the Mani- the privatization of a health information sys- toba Medical Association (MMA) and other tem known as SmartHealth. SmartHealth was organizations and individuals raised concerns launched in 1993 as a wholly-owned subsidiary about the security and privacy of personal health of the Royal Bank of Canada to investigate the information contained in databases. As a result, application of technology to monitor use of the the Manitoba government introduced The Per- health care system in order to reform parts of the sonal Health Information Act in 1998. This leg- system and decrease public health care islation established a process to ensure the secu- expenditures. To test its system, SmartHealth rity of personal health information by setting offered a free assessment of Manitoba’s health limits on its collection, use, disclosure and de- care system at a cost of $1 million to the Royal struction. The provincial Ombudsman is respon- Bank. In December 1994, SmartHealth was sible for enforcing the act.42 Opposition critics awarded a contract to develop the Health Infor- had suggested that a Privacy Commissioner be mation Network. In 1996, the Manitoba govern- established to deal with privacy concerns. For ment created the Health Information Services of many organizations and individuals concerned Manitoba Corporation to partner with about privacy and security, the legislation did SmartHealth. Loan guarantees and additional not fully address these issues. financing worth $166 million was provided to fund the partnership.39 Since that time, the 40Jim Silver, “Privatization by Stealth: The Growth of Pri- vate, For-Profit Health Care in Manitoba”, Quarterly Review Vol. 1, No. 1; Canadian Centre for Policy Alternatives: 1999, 38Dan Lett, “Food fiasco costs millions,” Winnipeg Free pp. 1-3. Press: December 3, 1999, pp. A1, A4. 41Manitoba Health, Annual Report 1997-1998. 39Dan Lett, “Health card quietly killed,” Winnipeg Free 42Health Canada, Provincial Health System Reform in Press: December 11, 1999, pp. A1, A4. Canada - Manitoba Version 3, Health Canada: 1997, p. 30.

Page 27 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Other concerns raised with the privatization of the provincial government may have been anx- the Health Information Network, include the ious to settle with SmartHealth in order to avoid links of the Royal Bank and EDS to the private a public court battle in the months prior to an health insurance industry, as well as the applica- election campaign. It is estimated that Smart- tion of the HIN to “eliminate waste” by moni- Health will cost the Manitoba government $34 toring—and therefore limiting—insured million, without achieving its main goals.45 diagnostic procedures and prescription drugs covered by the provincial Pharmacare b. Privatization of medical services program.43 Critics argued that if EDS and the Royal Bank have interests in the private health Most of the privatization of health care services insurance industry, as well as access to the in Manitoba and Saskatchewan has not occurred personal health data of Manitobans, a potential in bold transfers to for-profit corporations. Pri- conflict-of-interest may exist where the data vatization has occurred in a less obvious way by contained in the HIN is used to justify moving moving the delivery of medical services outside medical costs from the state to the individual, of traditionally defined hospitals. In a letter to thus creating a greater need for private provincial and territorial Ministers of Health insurance. Concerns were also expressed dated January 6, 1995, then federal Minister of regarding the ownership of the technology given Health Diane Marleau reported on a legal opin- that public money would be used to develop ion regarding the interpretation of the definition technology that would be owned and marketed of hospital as contained in the Canada Health by private, for-profit corporations. Act to be “any facility which provides acute, rehabilitative or chronic care...[which was] The SmartHealth program was projected to save clearly intended to ensure that Canadian resi- $700 million over ten years.44 Throughout the dents receive all medically necessary care with- HIN construction process, several critics of the out financial or other barriers and regardless of plan voiced their concerns that SmartHealth was venue.”46 However, the cost and provision of making minimal progress towards its goals and medical procedures deemed to be taking place costs were well over budget. However, Smart- outside of “hospitals” often are shifted to indi- Health had advocates within government and viduals. continued to receive government funding. On December 11, 1999, the Winnipeg Free Press In Manitoba, physiotherapy and occupational reported that the former Progressive Conserva- therapy are considered insured services when tive government had discontinued the initiative they are provided on a physician’s referral in a in late 1998 by offering a settlement worth $17 hospital facility.47 However, these services are million. Reasons for ending the SmartHealth not insured when provided in private clinics. contract included the corporation’s billing to the Therapy services are provided by Community province for work that had not been approved in the original contract, as well as concerns about the corporation’s efforts to secure similar con- 45Dan Lett, “Health card quietly killed,” Winnipeg Free tracts in Ontario and Newfoundland. In addition, Press, December 11, 1999, pp. A1, A4. 46Colleen Fuller, Privatization in British Columbia (Draft Report), BC Centre of Excellence for Women’s Health: March 1999, p. 6. 43Silver, 1999. 47Health Canada, Provincial Health System Reform in 44Fuller, 1998, p. 221. Canada - Manitoba Version 3, Health Canada: 1997, p. 29.

Page 28 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Therapy Services, Inc. (a private, non-profit In 1990, a study of laboratory services by the corporation under contract to Manitoba Health Saskatchewan Department of Health found that and some rural RHAs) to personal care home private laboratories were charging higher fees residents and urban and some rural home care than public laboratories for the same services.51 clients, without user fees.48 In 1993, the Minister of Health announced that the provincial government would stop providing According to the Association of Physiothera- funding to private laboratories on a fee-for-ser- pists of Manitoba (the regulatory body for phys- vice basis. At the time, the government expected iotherapists in Manitoba), the number of private that public sector labs would assume responsi- physiotherapy clinics has increased in recent bility for most processing, although private years. Many of the clients who use private phys- companies might continue to operate in a sup- iotherapy clinics have their fees covered by portive role. However, under health reform, the private insurance, the Manitoba Workers’ Com- Saskatchewan government transferred responsi- pensation Board or the Manitoba Public Insur- bility for laboratory services to the district ance Corporation (the public auto insurance health boards. The district boards were given the corporation). Fees at private clinics are typically option of using a public laboratory system or $35 to $40 per visit but are not regulated. One entering into a partnership with a private labora- of the most common reasons for using private tory. The Regina Health District contracted with physiotherapy is the reduction in waiting times the private health services company, MDS, to as compared to physiotherapy provided in hos- provide laboratory services, but has recently re- pital. Patients can wait up to eight months for duced that contract to equipment and collection treatment in a hospital or other insured facility. services. MDS has a partnership arrangement There is anecdotal evidence that some hospitals with local doctors to provide laboratory services directly refer patients who have some type of within the Saskatoon Health District. MDS used private insurance or other coverage to private to have contracts to provide private laboratory physiotherapy practitioners.49 No data was services in Prince Albert and East Central found regarding quality of care comparisons Health Districts, but after studying their options, between public and private, for-profit facilities. these districts decided to operate their own public laboratory services.52 Medical laboratories have been another site of privatization in Manitoba and Saskatchewan. Medical laboratories in Manitoba are structured According to the Saskatchewan Commission on under private, for-profit and public, non-profit Directions in Health Care, “[i]n recent years, service delivery models. There are 22 private private laboratory services have proliferated in for-profit laboratories in Manitoba that perform the province, particularly in the large urban 27% of the test volume in Manitoba. Routine centers, and the costs and utilization associated laboratory services, performed in private physi- with them have risen dramatically.”50 cians’ offices, are usually performed by laboratory assistants and consist of a short list of stan-

48Manitoba Health, Annual Report 1997-98. 49Brenda McKechnie, Association of Physiotherapists of Manitoba, personal communication, March 1999. Used with 51Beth Smillie, “A Deal in the Making,” Briarpatch Vol. 23, permission. No. 3, April 1994, p. 20. 50Saskatchewan Commission on Directions in Health Care, 52Canadian Union of Public Employees (CUPE), Protecting Future Directions for Health Care in Saskatchewan, Regina: Public Health Care, CUPE Saskatchewan Policy Paper, Government of Saskatchewan, 1990, p. 146. March 1999, p. 8.

Page 29 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan dard tests—there are 769 such private physi- nized as a health reform strategy in Manitoba cians’ laboratories in Manitoba that perform 3% and Saskatchewan designed to reduce health of the test volume in the province. There are 70 care expenditures. This shift in caring responsi- public laboratories in Manitoba which are block bility is built on women’s traditional gender funded by Manitoba Health. These include sev- roles as caregivers. Often the women engaged in eral large public sector laboratories in the City this caring work are unpaid, informal caregivers of Winnipeg and the Laboratory Imaging Ser- acting in their capacity as spouses, family mem- vice units in rural and northern Manitoba. These bers and friends. Paid caregivers are also over- public sector laboratories perform 27% of the whelmingly women. test volume in Manitoba. There are eight public sector laboratories located in Winnipeg hospi- Shifting care out of institutions transfers the tals that perform 43% of tests in Manitoba by costs of health care to the individual, in terms of volume. These laboratories are funded through prescription drugs and medical supplies. This their respective global hospital budgets.53 shift of caring responsibility also opens the door As a result of the regional governance models to private, for-profit provision of home health under health reform, responsibility for rural care services and private ownership and opera- diagnostic services were moved to the RHAs in tion of long-term care facilities. Provision of 1997. Manitoba Health remains active in a con- care is privatized as more of the caring work sulting capacity to the RHAs regarding labora- becomes invisible, transferred to women in the tory and imaging services. The Cadham Provin- home. cial Laboratory has served Manitobans as their public health laboratory since 1897. It has the The costs of hospitalization account for a major sole responsibility for several province-wide portion of provincial health budgets. As govern- public health surveillance and diagnostic ser- ments of all political stripes have focused on vices. It is also the central reference laboratory reducing deficits, the reduction in hospital ser- for the province.54 vices has been seen as an important strategy for controlling public expenditures. Between D. SHIFTING FROM INSTITU- 1991/92 and 1994/95, 1,200 hospital beds were removed from the health system in Saskatche- TIONAL TO HOME AND wan. Over 50 hospitals throughout the province COMMUNITY-BASED CARE have been closed or converted into community health centers. Part of the rationale for reducing In terms of health care privatization, there is hospital beds was the argument that dollars perhaps no better example of shifting the cost saved could be redirected to more appropriate and delivery of health care services to the indi- home and community-based care. Between 1992 vidual than the trend of shifting care from insti- and 1998, 1,317 acute care hospital beds were tutional settings to home and community-based closed in Manitoba, reducing the ratio of acute settings. Shifting care into the home is recog- care beds from 4.8:1,000 persons to 3.6:1,000 persons.55

53National Union of Public Government Employees (NUPGE) Web Site, Medical Laboratory Workers Survey. 55Manitoba Health, Annual Report 1992/93 and Annual 54Manitoba Health, Annual Report 1997-1998. Report 1997/98, Manitoba Health: 1993, 1998.

Page 30 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

1. HOME CARE Both public, non-profit and private, for-profit home care providers are in place in Manitoba Both Manitoba and Saskatchewan offer some and Saskatchewan. A shift in health care costs form of publicly-funded home care program. In to the individual has taken place as drugs and Manitoba, home care is an insured service, supplies covered while a patient is in the hospi- while in Saskatchewan, home care is delivered tal become the responsibility of individuals by health districts which receive provincial when that patient is moved into the home. Both funding and charge user fees. Increases in the provinces have introduced some programs to use of home care services and an increase in the help off-set these costs. In Manitoba, for-profit acuity of home care needs has occurred in both enterprises have taken advantage of this shift by provinces as the result of moving care out of commercially providing medical supplies and institutions into the home and the “community” equipment to private individuals. The most sig- as a means of reducing health care costs. Health nificant, and invisible, impact of an increased policy-makers in both provinces recognize that use and acuity of home care services in Mani- it is cheaper to provide long-term care in the toba and Saskatchewan has been felt by unpaid home or in “community” settings, such as per- caregivers in the home, who are usually women. sonal care homes, rather than in acute care beds in hospitals. It is also more cost-effective to discharge surgical patients soon after surgery a. Home care in Manitoba and have follow-up treatment occur in the home, as well as to perform surgery on an outpatient Manitoba was the first province to introduce a basis. Care and treatment outside of institutional comprehensive system of continuing care in settings may cost the health care system less 1974. The public system provides medical, reha- because of savings in terms of labour and facil- bilitation and support services at home to any ity costs, but it is also true that savings are real- person who is assessed as requiring these ser- ized because individuals bear a greater responsi- vices. The system also includes an appeals pro- bility for health care costs when that care is not cess for individuals who believe they have not delivered as part of a hospital stay. been fairly assessed.57 The Home Care Program is part of a continuum of services that include A key principle of health reform in Saskatche- respite services, day programs and personal care wan is to provide health services in the com- homes. munity wherever possible. The provincial government and district health boards have Previously operated under the Office of Con- encouraged this shift to community care by tinuing Care within Manitoba Health, RHAs more than doubling spending on home-based services since 1991, to $67 million. At the took control of the Home Care Program in 1997 same time, spending on acute care has and 1998. In Winnipeg, the Home Care Program dropped 14 per cent, to $585 million. Today, was operated by the Winnipeg Long Term and patients are staying in hospital one day less Community Care Authority (WCA), which has than they did in 1991. One in four home care recently been amalgamated with the Winnipeg clients now receives home treatment which Hospital Authority into the newly formed Win- might otherwise have been provided in hospi- nipeg Regional Health Authority. tal, up from one in 10 in 1991.56

56Health Services Utilization and Research Commission 57Evelyn Shapiro, The Cost of Privatization: A Case Study of (HSURC), Hospital and Home Care Study, Summary Report Home Care in Manitoba, Canadian Centre for Policy Alterna- No. 10, Saskatoon: HSURC, 1998, p. 1. tives, 1997, p. 1.

Page 31 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

The Manitoba Home Care Program’s objectives cal patients and people with disabilities; and are: about 5% of service users are children with se- vere disabilities. More women use home care P to provide effective, reliable and responsive services than men. Old age, poor health, disabil- community, health care services to Manito- ity, poverty and gender are determinants of bans to support independent living and pro- home care use.59 vide care in the community; P to develop appropriate care options to A Self-Managed Home Care Program was re- institutionalization that are acceptable to the cently established in Manitoba. In 1997 there consumer/family for persons who can be were 102 home care clients participating in this appropriately maintained in the community; program. Self-managed care allows eligible and clients to take responsibility for directly manag- P to facilitate in collaboration with con- ing their own non-professional health services, sumer/family admission to appropriate insti- such as personal attendant care, previously pro- tutional care when living in the community vided by the Home Care Program.60 Disability is not a viable alternative.58 rights advocates have expressed support for the program’s capacity to increase independence In Manitoba, the provision of home care ser- and autonomy of people with disabilities. Union vices is mostly provided by the public system, activists have expressed concern that this trend without additional user fees. This system in- may lead to increased use of private services. cludes case coordinators, managers, nurses, home care attendants and homemakers. There The following policy and population trends are also a number of private, for-profit compa- point to an expected increase in the need for nies that provide home care services, such as home-based care in Manitoba: nursing, companionship, meal preparation, personal care and cleaning. These services are paid P the growth in the number of older Manito- for by the consumer and may be covered by bans; private insurance. No data was found on the P independent living initiatives for people with share of home care services provided by the disabilities; public system as compared to the private system P reduction in length of medical and surgical in Manitoba. hospital stays; and P reduction in the ratio of personal care home In Winnipeg, 75% of home care consumers beds to Manitobans over 75 years of age.61 receive long-term services, the remainder receive services over a short period of time, usu- b. Home care in Saskatchewan ally for post-surgical or medical care after an early discharge from hospital. Elders comprise Saskatchewan introduced a program of home about 75% to 80% of home care recipients; care services in 1978 and by 1984 home care about 20% of service users are adult post-surgi- programs were delivered in home care districts

58Manitoba Advisory Committee to the Continuing Care Pro- 59Shapiro, 1997, pp. 5-6. gram, Home Care Reform: Challenge and Opportunity, Man- 60Manitoba Health, Annual Report 1997-98. itoba Health: 1996, p. 3. 61Shapiro, 1997, p. 7.

Page 32 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

throughout the province. In 1990, the Saskatche- P to provide a sense of security to caregivers wan Commission on Directions in Health Care, and dependent people living at home, per- which had been appointed by Premier Devine, sonal emergency response systems— strongly recommended an expanded and com- electronic devices which connect their wear- prehensive system of home care. While the ben- ers with the nearest hospital or other desig- efits to patients were clearly part of the rationale nated emergency monitoring centre—should for expanding home care services, the cost sav- be introduced as part of the home care pro- 63 ings of keeping people out of health care institu- gram within each division. tions was also an important consideration. The Commission stated: “[t]he support services pro- The Commission acknowledged that an in- vided by home care offer an attractive alterna- creased reliance on home health care required tive to costly institutionalization for residents community-based support services and the ac- requiring assistance to live independently.”62 tive participation of family caregivers. While acknowledging the financial, social and emotional consequences often faced by family care- The Commission recommended that: givers, the Commission endorsed the provision of respite services, counseling and education P the home care program in each division services as a way to “assist and encourage fami- should provide a full range of health care and lies and friends to assume the role of caregiver other supportive living services to all resi- in the home.”64 dents, including the elderly, the young disabled, the mentally handicapped, the men- In 1994, home care services were integrated tally ill and those with head injuries, who with other health services under the jurisdiction require these services to remain independent of newly-formed district health boards. In Sas- and at home for as long as possible; katchewan, all health districts provide acute, P the home care program in each division palliative and supportive home care services to should include nursing, home support, and residents. Services may include assessment and rehabilitation services delivered through a coordination of care, nursing, homemaking, combination of staff and volunteers recruited meals, friendly visits, transportation, physical by the home care program as well as other therapy, occupational therapy, social work, tele- community-based programs and agencies; phone surveillance, and home maintenance. P user fees for home care services, based on the principle of accessibility, should be es- Home care services in Saskatchewan have ex- tablished on a province-wide basis to ensure panded and now include services formerly pro- equity for clients and division councils; vided in institutions, such as intravenous ther- P there should be no charges for nursing and apy and palliative nursing, as well as affiliated rehabilitative services; professional services, such as occupation or P there should be charges for certain home physical therapy. This shift reflects the trend to support services such as home maintenance provide health care services in the home, which and meals on wheels; and were once provided in institutions. Some have

62Saskatchewan Commission on Directions in Health Care, 63Ibid., pp. 65-66. 1990, p. 64. 64Ibid., p. 67.

Page 33 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan suggested that resources have shifted to support 1991/92 and 1994/95 hospital stays have been a more “medicalized” model of home care, and reduced by a total of 375,000 patient days; day away from meal services, homemaking and surgery has increased from 44% to 53% of all personal care services. surgeries; and acute care services provided in the home (such as intravenous therapy and pal- In 1997/98, the Saskatchewan government spent liative care) have increased 83%.66 $67.8 million on home care, which represented 4.2% of the total provincial health budget. There In order to support the shift from institutional to are no fees for health district home care services “community” care, Saskatchewan Health dis- provided by nurses, case managers, occupa- tricts have changed their health care expendi- tional therapists, physical therapists or social tures. Eighty-two percent of district budgets in workers. Fees are charged for homemaking, 1996/97 went to institutional services, such as meals and home maintenance services. Accord- hospitals and nursing homes, compared to 89% ing to Health Canada, “co-payment by the client in 1991/92. The difference has been redirected is required based on income and the number of to home and community services.67 services required. Clients are charged $5.45 per unit of service for the first 10 chargeable units According to Manitoba Health’s 1997/98 An- of service received in a month. Charges for ad- nual Report, there were 30,257 persons regis- ditional units are adjusted in accordance with tered with the Home Care program in 1997/98, clients’ income levels. Effective September 1, representing an 11% increase over 1996/97. 1997, the maximum charge per month ranges Between 1995/96 and 1996/97 home care clients between $54.50 and $331.00. Clients receiving increased by 15%.68 While the number of home social assistance and seniors receiving the pro- care clients is increasing, there is also a continu- vincial income supplement to Old Age Security ing trend toward the provision of more acute pension, are charged at the minimum.”65 care in the home. Since 1996/97 the provision of nursing services in the home increased by 15% c. Increases in home care in Manitoba and the provision of personal services, such as and Saskatchewan assistance with bathing, has increased by 22%. In 1997/98, home care expenditures totaled 69 Saskatchewan Health notes that between $123,942,100 or about $4,000 per client. 1991/92 and 1994/95, the amount of home care services have increased by 38%. In addition, the As Table 5 and Table 6 indicate, the use of type of care provided in the home has changed, home care services has increased in the time with more resources going to acute and pallia- period when reforms to the health care system tive care. Between 1991/92 and 1994/95 pallia- are taking place in both Manitoba and Saskatch- tive care services at home have increased by ewan. 130%, serving 39% more palliative care clients at home. More acute care is being performed in the home as hospital stays are reduced. Between 66Saskatchewan Health, Health Renewal is Working: Pro- gress Report, 1996, pp. 3-5. 67Ibid., pp. 3-5. 68Health Canada, Provincial Health System Reform in 65Health Canada, “Health System Reform in Saskatchewan,” Canada - Manitoba Version 3, Health Canada: 1997, p. 23. Health Reform Database: Overview by Province,1998/99, p. 69Manitoba Health, Annual Report 1997/98; Manitoba Health 20. www.gov.mb.ca/health/ann/3a-m5.html

Page 34 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

70 TABLE 5: SASKATCHEWAN HOME CARE CLIENTS zation and Research Commission, there is very AND AMOUNTS OF HOME CARE SERVICE, little use of private home care in the province, 1994-97 but it is not completely clear what is meant by that term.. Does it include private nursing ser- Number of Year Units of Service vices, non-profit services for seniors, and/or Clients privately-run personal care homes? 1994-95 23512 1913438 The expansion of privately-delivered home care 1995-96 25704 2117464 services may be an unintended consequence of policies designed to keep people out of institu- 1996-97 27410 2243037 tions, while failing to provide sufficient public Source: Canadian Home Care Association, Portrait of home care services to meet their needs. The Canada: An Overview of Public Home Care Programs, former Deputy Minister of Health recalled that (draft) February 1998. “[d]uring this reform period, where there was a shift in the burden of paying for or delivering TABLE 6: MANITOBA HOME CARE CLIENTS certain health or family support services, there 1992-98 was no instance I can remember where the intention was to move the service to a for-profit Year Number of Clients centre. Or for that matter, I don’t recall moving 1992/93 24460 public services to non-government, non-profit agencies (although there may have been a small 1993/94 25121 example of this.) If either of these forms of service centres acquired new business as a result of 1994/95 Not available the health reform, it would have occurred as a 1996/97 29783 consequence of shifting the burden of payment or family support back to the family unit...who 1997/98 30257 then consequently might have used a third party to help them (and accordingly paid privately).”71 Source: Manitoba Health, Annual Report: 1992-1998. According to the Canadian Home Care Associa- d. Privatization of home care: shifting tion, user fees for chargeable home care services the provision of care to for-profit in Saskatchewan total approximately $6 million providers and unpaid caregivers per year.72 According to a recent CUPE policy paper, “the shift from institutional to community For the most part, health reforms in Saskatche- care has resulted in more health services being wan have not directly transferred publicly-deliv- paid for and delivered privately.”73 ered health services to for-profit or non-profit service providers. However, by shifting more responsibility for caregiving to families, they may have indirectly created a market for private 70Health Services Utilization and Research Commission, health care and home support services. For in- Hospital and Home Care Study, Summary Report No. 10, stance, the yellow pages of the Saskatoon phone 1998. 71 book list businesses or agencies which provide Adams, 1999, personal communication. Used with permission. home nursing, personal care, and homemaking 72 Canadian Home Care Association, 1998, p. 2. services. According to the Health Services Utili- 73Canadian Union of Public Employees, 1999, p. 2.

Page 35 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

It is difficult to track the changes in home care that there would be no lay-offs for the duration service delivery and actual patterns of private of the contract; that the private contract would expenditures on home care, as they vary across be confined to 20% of personal services out; and health districts, and there does not appear to be that the privatization initiative would be evalu- a provincial data base which gathers this infor- ated in two years. mation for the whole province. Some sources indicate that user fees for home care services In March 1997, the Manitoba government an- have declined, while others suggest that per- nounced that Olsten Health Services, a corpora- sonal support and homemaking services are tion in the United States (U.S.), would provide subject to more charges and are less available nursing, home attendant and home support ser- than in the past. Each health district determines vices to all new long-term care clients in certain the range of home care services offered within areas of Winnipeg. This amounted to 10% of the that district. Some districts have shifted home workforce, as opposed to the government’s goal care resources to acute care and nursing while of privatizing 25% of these services. Some ana- cutting back on homemaking and personal sup- lysts of the government plan concluded that this port services which help people maintain their reduction in the amount of services to be con- health and independence. There is also variation tracted out had occurred because there were no within health districts, with rural residents hav- private bids that could provide the volume of ing access to fewer home care support services service that had initially been slated for privat- than their urban counterparts. ization.75

Most formal home care services are delivered In December 1997, the government announced by health districts. In addition to the services that the contract with Olsten would not be re- provided by paid home care workers, health newed. This announcement coincided with the districts organize programs of community vol- result of a Canadian Centre for Policy Alterna- unteers to provide various services including tives paper that reported FBI investigations of meal delivery, friendly visits, transportation, Olsten Corporation for improper Medicare bill- and home maintenance. In 1990, approximately ing in the U.S.. The paper also described Olsten 18,000 volunteers provided 126,000 hours of as “a U.S. based multinational corporation... home care services.74 [that is] largely non-unionized...[and] has been charged by the State of Washington for alleg- In April 1996, the Manitoba government an- edly failing to carry out physicians’ instruc- nounced its intention to privatize 25% of per- tions.”76 sonal care services provided by the Manitoba Home Care Program. Estimates of cost savings Several concerns were expressed by critics of from this initiative ranged as high as $10 mil- the government about the province’s plan to lion. This move resulted in a five-week strike by privatize elements of the home care system. Al- home care workers belonging to the Manitoba though the plan to privatize home care was not Government Employees Union (MGEU). The contract that ended the strike assured employees

75Shapiro, 1997, pp. 1-13. 76Jim Silver, The Cost of Privatization: Olsten Corporation 74Saskatchewan Commission on Directions in Health Care, and the Crisis in American For-Profit Home Care, Canadian 1990, p. 64. Centre for Policy Alternatives: 1997.

Page 36 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan ultimately successful in Manitoba, these con- tients more carefully and place them in the cerns can provide a framework for analyzing setting most appropriate to their needs. Fre- other privatization initiatives: quently this is seen, however, as keeping people less time in hospitals, or not admitting 78 P privatization would result in lower wages for them to nursing homes. care-providers, failing to attract and retain While publicly-funded, publicly-provided home qualified service deliverers; P privatization would lead to loss of control care services have clearly increased, it is impor- over standards, planning and administration, tant to remember that most home health care is leaving the system open to over-billing; provided by informal caregivers within the fam- P clients would be pressured to purchase addi- ily. To support unpaid caregivers, Saskatchewan tional costly and un-prescribed health sys- Health reports that respite beds have increased tems by private care providers; and 44% and respite days in nursing homes have 79 P a private home care system would not in- increased 54% between 1991/92 and 1996/97. clude an appeals process.77 In 1995, the Seniors Education Centre at the Health reforms have been founded upon certain University of Regina conducted in-depth com- assumptions about the caregiving responsibili- munity consultations with caregivers and ser- ties of families. These assumptions and the val- vice providers. The resulting video and discus- ues they reflect need to be examined more sion guide portray the experiences and insights closely. As public support for “personal” care of several informal caregivers and present the has declined, public resources for home care following information: may be increasingly focused on medical procedures and nursing care. The provision of social, P every day in Saskatchewan more than 80,000 emotional and practical support for independent informal caregivers provide assistance and living, while recognized as important determi- support to chronically ill, disabled or elderly nants of health, continue to be defined as a pri- adult family members. Some fulfill this role vate responsibility. The following quote from while also maintaining full-time jobs, while the former Saskatchewan Deputy Minister of raising children of their own, or while grow- Health reveals how the issues related to home ing more elderly and in need of care them- care are currently being framed. selves; The rapid expansion and use of Home Care P three out of four caregivers are women, be- services may be seen as a transfer of services tween 50 and 65 years of age; to private care. I never saw it this way al- P as many as 10% of female caregivers are though I recognized that the family was pick- over the age of 75; ing up a larger private responsibility for “per- P almost half of all seniors age 65 to 74 live sonal” not “nursing” care....There has not with some form of disability; and (been) so much a ‘transfer of health care delivery from institutions to private households’ as there has been a systematic attempt in the health system to assess the conditions of pa- 78Adams, 1999, personal communication. Used with permission. 79Saskatchewan Health, Health Renewal is Working: Pro- 77Silver, 1997, p. 2. gress Report, 1996, pp. 3-5.

Page 37 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

P the actual cost to the health care system of of Government Services, with the exception of maintaining a person in a long-term care the wheelchair program, which is run by the facility is approximately $3,000 per month. non-profit Society for Manitobans with Disabili- Clients and their families typically pay about ties.82 one third of that cost. Thus, by keeping family members at home, informal caregivers According to Saskatchewan Health, “Financial save the health care system more than $2,000 barriers to increased use of home care are being per month or $24,000 per year:80 removed. Certain palliative supplies and drugs are available to clients without charge. As well, e. Privatizing home care: transfer of home care clients receive IV drugs and supplies, costs to individuals and certain home care nursing supplies, such as medical dressings, without charge. Health dis- One result of early discharge from hospital of tricts may even reduce or waive client fees in surgical and medical patients has been the trans- cases of financial hardship.”83 In addition to fer of costs for medical supplies to the individ- user fees for home care services delivered by the ual. While in hospital, costs for prescriptions health district, “patients receiving home care are drugs, as well as medical supplies and equip- charged for some drugs and supplies provided at ment, are insured. In the home setting, individu- no cost to patients in hospitals.”84 Some of these als bear these costs. While Manitoba and Sas- supplies may be covered by the health district katchewan have created some programs to help and some equipment is available on loan, as cover these costs, more and more responsibility well some districts provide funding for medical for paying for the materials of health care fall to alert systems. individuals. In Manitoba, the transfer of costs for medical The Manitoba Home Care Equipment Program supplies and equipment to the individual is also covers part of the costs and maintenance of contributing to the privatization of the provision some equipment and supplies, such as wheel- of these supplies, as for-profit businesses take chairs. The program loans medical equipment advantage of newly-created markets. A few and supplies for use in the home on a referral by years ago, a for-profit medical supply store a medical practitioner. While the number of (Stevens Medical Supply Store) opened in the individuals using the program has increased Health Sciences Centre in Winnipeg so that over the years, the number of services provided patients and their caregivers could purchase has decreased. In 1987/88, the Home Care these supplies after being discharged from the Equipment Program provided 35,213 services to hospital. 15,487 individuals.81 By 1997 the program was providing 28,952 services to 23,310 individuals. In 1997, the Manitoba government signed a In 1996/97 responsibility for this program was two-year contract with Rimer-Alco North transferred to the Materials Distribution Agency America (operating as RANA-Medical) to provide home oxygen services under the Manitoba

80Living for Others: the life stories of older women in Saskat- chewan, Seniors Education Centre, University of Regina, 82Manitoba Health, Annual Report 1997-1998. 1995, excerpts from the video and from the discussion guide, 83Saskatchewan Health, Annual Report, 1997-98, p. 20. p. 1. 84Health Services Utilization and Research Commission, 81Manitoba Health, Annual Report 1988-89. 1998, p. 9.

Page 38 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Home Oxygen Therapy Program.85 This con- In Saskatchewan, “special care homes” are tract is worth about $1.4 million and affects 800 publicly-funded nursing homes which provide clients. RANA-Medical will supply oxygen, as higher levels of care, while “personal care well as follow-up monitoring by respiratory homes” are primarily privately-owned facilities therapists. The Manitoba Association of Regis- which charge residents fees. In the early 1990s, tered Respiratory Therapists (MAART) ex- the Health Services Utilization and Research pressed concern that it had not been involved in Commission (HSURC) conducted a study of the process leading to the decision to privatize long-term care in the province. Citing data which showed that the numbers of long-term oxygen services. The government cited cost care beds per thousand residents over age 75 savings as the reason for privatization, although was higher in Saskatchewan than in several three earlier government-commissioned reports other jurisdictions, HSURC argued that the pro- concluded that private supply of home oxygen vince was faced with “an excessive and costly services would be more expensive than the cur- dependence on institutional care.”88 The fact rent publicly-provided services.86 that all these beds were occupied was inter- preted as an indicator that long-term care 2. LONG-TERM CARE providers had a financial incentive to keep the beds filled rather than a measure of the “true Part of the shift to less expensive care settings level of need for institutional care.”89 HSURC included moving long-term care patients out of also found that long-term care providers were acute care beds into a variety of facilities and not given incentives to admit patients with high settings, such as nursing homes and personal levels of care requirements. As a result, often care homes. Both Saskatchewan and Manitoba those persons with greatest need had to wait experienced a significant loss of acute care beds longer for access to long-term care facilities. as a result of health reform measures. One of the The study also found that people requiring long- term care were being kept in more expensive arguments for closing these beds was that many acute care hospitals.90 of the patients in acute care beds could be adequately served in long-term care facilities. In Reasoning that institutional care can have nega- Manitoba, 436 new personal care home beds tive effects on patients’ physical and mental were opened between 1992 and 1998, at the abilities, as well as their sense of independence, same time as more than 1,200 acute care beds HSURC concluded that “Saskatchewan’s long- were closed.87 In Saskatchewan, the number of term care sector needs a major overhaul” and people living in special care homes has de- recommended restructuring “to better serve creased as many seniors with lower care needs clients’ needs and recognize clients’ capacities now reside in privately-operated personal care for independent living.” Specifically, it recom- homes or private family homes. As a result, mended a reduction in the number of institu- more long-term care has been privatized. In tional long-term care beds and a need to focus Manitoba, costs of long-term care continue to be institutional care on higher need patients. It also transferred to the individual, even when that recommended that persons with light care needs care is received in a hospital setting.

88Health Services Utilization and Research Commission, 85Manitoba Health, Annual Report 1997-1998. Long-Term Care in Saskatchewan: Final Report, Saskatoon: 86“Praznik stands behind oxygen pact,” Winnipeg Free Press, 1994, p. 1. March 22, 1997. 89Ibid., p. 1. 87Manitoba Health, Annual Reports: 1992-1998. 90Ibid.

Page 39 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

be encouraged to remain independent in their care homes “represents a shift in funding and own homes by expanding home care, respite responsibility from the public to individuals to services, adult day care and other community- pay for private care.”94 based support services.91 In 1996, the Saskatchewan government changed In 1992, the Saskatchewan NDP government the regulations governing personal care homes. stopped direct funding to long-term care facili- Under the new regulations, personal care homes ties for persons requiring light (Level 1 and were allowed to operate up to 40 beds, rather Level 2) care. This was part of a larger trend than the existing ten-bed limit. By 1999, there toward encouraging people to live at home or were 40 personal care homes with more than ten outside government-funded long-term care insti- beds. Health care unions, operators of smaller tutions. In 1976, there were 1,702 Level 1 beds personal care homes, and members of the Lib- in government-funded nursing homes, but by eral opposition all criticized the government for 1996, this number had dropped to 16. Between opening the doors to larger, private, for-profit facilities and transferring responsibility for light 1985 and 1994, 94% of the Level 1 beds and 95 69% of the Level 2 beds were removed from the level long-term care to the private sector. health system.92 According to CUPE, “since 1996, the number of personal care home beds has increased by Some of those who promoted deinstitutionaliza- 28%....[this] represents a shift in funding and responsibility from the public to individuals to tion argued that families were “dumping” their pay for private care....Personal care homes are elderly relatives in long-term care facilities creating low-wage ghettos. Because there is no which were not appropriate for those with light government funding to personal care homes, care needs. This value-laden terminology de- private operators are paying low wages in order fines light care as a family responsibility and is to keep resident fees somewhat affordable and used to justify the withdrawal of public funding still make a profit.”96 for this type of service. While deinstitutionalization may indeed have benefits, the decision to Saskatchewan continues to have the highest stop public funding may have been driven by proportion of persons over 75 living in special the desire to reduce expenditures, as much as it care (e.g., nursing) homes, though under health was based on evidence of the health benefits. reform their numbers have declined. Between 1992 and 1998, the number of Saskatchewan Many of the people requiring light levels of care people living in special care homes dropped by have remained in their own homes or moved more than 10%, from 10,141 residents to 9,111 into personal care homes. By January 1999, residents.97 Between 1991/92 and 1996/97, Sas- there were 256 personal care homes in Sas- katchewan’s nursing home bed ratio dropped katchewan with a total of 2,087 beds, only six of from 158 beds per 1,000 people over 75 years of these personal care homes in the province were age to 143 beds per 1,000 people over 75 years operated by non-profit corporations.93 Between of age, getting closer to the national average of 1996 and 1999, the number of personal care 129 per 1,000 people over 75 years of age.98 home beds in the province rose 28%. According to CUPE Saskatchewan, this rise in personal 94Ibid., p. 3. 95Murray Mandryk, “New rules said to make care less personal,” Regina Leader Post, May 14, 1996. 91Ibid., p. 1. 96Canadian Union of Public Employees, 1999, p. 3. 92Canadian College of Health Service Executives. Health 97Saskatchewan Health, Annual Report, 1997-98, p. 21. Reform Update 1996-97, 1997, p. 49. 98Saskatchewan Health, Health Renewal is Working: Pro- 93Canadian Union of Public Employees (CUPE), 1999, p. 3. gress Report, 1996, pp. 3-5.

Page 40 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

In Manitoba, long-term institutional care is 3. MENTAL HEALTH SERVICES mostly provided in personal care homes. In 1998 there were 120 personal care homes in In Manitoba, mental health services have gone Manitoba licensed for a total of 9,105 beds. through extensive changes in the health reform Sixteen percent of Manitoba’s personal care process. One of the most substantial changes has homes are privately owned and operated. been moving clients from institutions into Eighty-three percent are operated by non-profit community-based care settings, that include bodies including religious or charitable groups, group homes and supported independent living and service organizations. Only one personal sites. Non-profit, non-government agencies, care home in Manitoba is owned and operated such as the Canadian Mental Health Association by the provincial government. and the Salvation Army have been partners in many of these initiatives, receiving funding to In Manitoba, the costs of long-term institutional provide services. The Brandon Mental Health care are covered by the individual receiving Centre, one of the province’s largest mental care, as well as the provincial government. All health institutions. was formally closed on residents of licensed personal care homes in March 31, 1998.102 Other mental health institu- Manitoba are assessed a daily residential charge. tions continue to operate in Manitoba. A sliding scale of rates based on income is established by the provincial government and The delivery of services by faith-based agen- reassessed each year. Effective August 1, 1997, cies, such as the Salvation Army, raises con- a new rate structure for personal care home resi- cerns for some clients, especially gay and les- dents was put into place. The minimum rate was bian clients. If faith-based agencies support a increased to $24.80 per day and the maximum traditional and patriarchal family model, women was increased to $57.90 per day.99 The maxi- who are lesbian, survivors of childhood sexual mum has since increased to $58.40 per day. abuse and/or family violence, may be less likely An amendment to the Manitoba Hospital Ser- to receive the services they need. vices Insurance and Administration Regulation passed on October 16, 1998 allows these per In July 1997, Manitoba Health announced that diem charges to be applied to persons in hospi- long-term psychiatric patients receiving care in tal awaiting beds in personal care homes. A a psychiatric facility would be charged income- 1999 study by the Manitoba Centre for Health based per diem rates. A long-term stay was de- Policy and Evaluation found that the average fined as being of a duration longer than 180 time an individual spends in hospital waiting for days. These fees are not applied to patients who 103 a personal care home bed was 108 days.100 If a are admitted involuntarily. Anti-poverty ac- personal care home bed has become available tivists raised concerns that these fees would be and an individual refuses to accept it, hospitals unmanageable for a population that relies on a are able to charge the full per diem cost for a fixed low income and may result in patients hospital bed.101 leaving facilities before their treatment was complete because they could no longer afford per diem rates. 99Manitoba Health, Annual Report 1997-1998. 100Manitoba Centre for Health Policy and Evaluation, “Bed Closures in Winnipeg: Problem or Progress?” 102Manitoba Health, Annual Report 1997-98. 103Health Canada, Provincial Health System Reform in 101Manitoba Gazette, Vol. 127, No. 42, p. 1394. Canada - Manitoba Version 3, Health Canada: 1997, p. 27.

Page 41 PART IMPACTS OF PRIVATIZATION 3 ON WOMEN

In 1987, women’s organizations in Saskatche- privatized? How have these changes affected wan protested against the Progressive Conserva- female health care workers, service users, and tive government’s substantial cutbacks in health unpaid caregivers? Within these broad catego- and social services. Writing in a journal pub- ries, which women have benefited from health lished by the Saskatchewan Action Committee reforms, and which have been harmed? on the Status of Women, Susan Dusel argued that reductions in state support for health care In attempting to answer these questions, we services would have particularly adverse effects searched government documents on health re- on women—as health care providers, as health form, as well as the health and social science service users, and as unpaid family caregivers. literature. We found very little evidence that health reform policies in either province have When the health care system is cutback been subject to any kind of gender analysis. The women get hit with a triple whammy. First, various forms of health care privatization and women tend to be the health care workers who their impact on women have received little at- are losing their jobs or are being run off their tention from health system planners or research- feet because of understaffing. Second, women ers. Yet women comprise the majority of those and their children tend to be the heaviest users employed in health care, those receiving care, of the health care system. Finally, women have to pick up the slack when the state no and those providing unpaid care in the home. longer funds health care services.1 Given the lack of research in this area, we can- Have the health care reforms of the nineties not provide a clear answer to the question, delivered a triple whammy to women? To what “How have the various forms of health care degree has the public health care system been privatization affected women in Saskatchewan cut back? In what ways has health care been and Manitoba?” What we attempt to do here is present evidence which shows how some forms of privatization have affected or may be affecting various groups of women. This tentative 1Susan Dusel, “Government puts the brakes on women’s evidence points to the need for further investiga- movement,” Network of Saskatchewan Women, Vol. 4, No. tion of the impact of health reform on women. 7, 1987, p. 4.

Page 42 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

A. WOMEN’S EMPLOYMENT IN TABLE 7: NUMBER OF WOMEN EMPLOYED IN HEALTH OCCUPATIONS, SASKATCHEWAN THE HEALTH CARE SYSTEM Full Time Part Time In Manitoba and Saskatchewan, as in the rest of 1990 1998 1990 1998 the Canada, over 80% of those employed in Health occupa- 2 12900 16500 7500 6000 health care occupations are women. Table 7 tions and Table 8 illustrate that the number of women employed full time in health occupations Professional occupations in health, increased in both provinces, between 1990 and nurse supervisors 5500 7600 3800 2700 1998. The number of women employed part and registered time in health occupations declined in Saskatch- nurses ewan, but increased in Manitoba during the Technical, assist- same time period. What these figures do not re- ing and related 7400 8800 3700 3300 veal are patterns of female employment within occupations specific health occupations, or the annual fluctu- ations within the decade. Neither do they cap- Source: Statistics Canada, Labour Force Historical ture any information on the nature of wage lev- Review, 1999. els or working conditions within these occupations. Yet income and working environments are TABLE 8: NUMBER OF WOMEN EMPLOYED IN known to be important determinants of health. HEALTH OCCUPATIONS, MANITOBA Full Time Part Time B. JOB LOSSES FOR WOMEN IN THE HEALTH SECTOR 1990 1998 1990 1998 Health occupa- 15300 17800 8100 9000 Government cutbacks in health care or changes tions in the delivery of health services have, at vari- Professional occu- ous times, led to layoffs of women employed in pations in health, health care occupations. nurse supervisors 6900 8300 3700 4000 and registered When the Conservative government in Saskatch- nurses ewan eliminated the school-based dental pro- Technical, assist- gram in 1987, over 400 dental workers lost their ing and related 8400 9500 4400 5000 jobs.3 The overwhelming majority of these occupations workers were women. Under the program, dental services had been delivered by a largely fe- Source: Statistics Canada, Labour Force Historical male profession of dental therapists, working Review, 1999. independently, in schools throughout the province, including many in rural communities. Den- workers represented by the Saskatchewan Gov- tal therapists were unionized public sector ernment Employees Union. When dental services were privatized, these jobs were eliminated and dental therapists were left to seek em-

2 ployment with dentists in private practice, most Statistics Canada, Labour Force Historical Review, 1999. of whom were located in urban centres. Accord- 3Elizabeth Smillie, “Dental Plan in Decay,” Network of Sas- katchewan Women, Vol. 4, No. 10, 1987-88, p. 6. ing to Opposition critics, the cancellation of the

Page 43 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

school dental program in Manitoba resulted in When the Saskatchewan government decided to job loss for approximately 50 dental health prac- stop funding Level 1 and 2 light nursing care for titioners, mostly women.4 residents of long-term care facilities, the gap in services was partially filled by private, for- Hospital closures and health care restructuring profit personal care homes. In some cases, have led to layoffs among health care workers. unionized workers who were laid off from long- According to the Canadian Union of Public Em- term care facilities were offered jobs in the pri- ployees in Saskatchewan, “The failure to imple- vatized personal care homes, at lower rates of ment a provincial labour adjustment strategy at pay.9 the beginning of health reform led to thousands of health care workers being laid off without The consolidation and privatization of food and 5 retraining opportunities.” other services within the health system has also been associated with job losses. An analysis of Expenditures on nursing and other health care the Urban Shared Services Corporation (USSC) staff represent a large portion of hospital bud- centralized food system, which was developed gets. Therefore when hospitals receive a funding to provide food to nine Winnipeg hospitals, pro- cut as part of the health reform shift to “commu- jected the loss of between 252 and 357 jobs.10 nity care,” savings are often made at the expense Unions in both provinces have opposed the con- of nursing staff. The Manitoba Nurses’ Union tracting out of laundry, meal and cleaning ser- estimates that more than 1,000 nurses were re- vices to private, for-profit corporations. moved from the health care system since 1992.6 The Manitoba NDP reported that approximately Nationally, health care is one of the most highly 500 other health care workers were laid off during the Progressive Conservative administra- unionized sectors for women in the paid labour 7 force. In 1993, 53.2% of women working in tion. The Saskatchewan Union of Nurses re- 11 ports that “as institutions slash costs, nursing health care belonged to unions. Unionized po- labour is the first target. Saskatchewan nurses sitions often mean higher wages, benefits, and have lost the equivalent of 579.5 full time posi- job security. The loss of unionized public sector tions since 1990, nearly a 10% decline.”8 In jobs for women in health care occupations could 1999, in response to nurses’ demands and public have an impact on women’s income, economic concern over nursing shortages, the govern- status and conditions of work, all of which are ments of both Manitoba and Saskatchewan have regarded as important determinants of health. made commitments to provide funding and im- Data comparing wages, benefits and job satis- prove conditions of work in order to recruit and faction between public sector and private sector retain more nurses. health care workers was not found.

4Shauna Martin, NDP Caucus Health Researcher, personal communication, March 1999. Used with permission. 9Canadian Union of Public Employees, Protecting Public 5Canadian Union of Public Employees, Protecting Public Health Care, CUPE Saskatchewan Policy Paper, March Health Care, CUPE Saskatchewan Policy Paper, March 1999, p. 3. 1999, p. 2. 10Philippe Cyrenne, Analysing Shared Service Contracts: the 6Manitoba Nurses Union, 1996, p. 9. Case of Food Services for Winnipeg Hospitals, Canadian 7Manitoba NDP News Release, “Filmon’s layoffs coming Centre for Policy Alternatives, June 1999; Canadian Union of back to haunt him,” February 9, 1998. Public Employees, Cooking Up a Storm: Part II, 1998, p.6. 8Saskatchewan Union of Nurses, “Health reform offering 11Canadian Labour Congress, Women’s Work: A Report, constraints and opportunities,” Spectrum, January 1998, p. 4. Ottawa: Canadian Labour Congress, 1997, p. 13.

Page 44 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Data concerning the representation of visible According to one SUN representative, “In the minority women, Aboriginal women and last five years, Saskatchewan nurses have expe- women with disabilities in the health care paid rienced enormous cumulative stress. RNs and employment sector is noticeably lacking. How- RPNs have watched administrators and nurse ever, shrinking employment opportunities or the managers toy with “mission statements” and transfer of jobs to the private sector could make “governance models” while nurses struggle to provide safe care with diminishing resources it more difficult for these women to gain access amidst the confusion and chaos of closures, to full-time, well-paid employment. According amalgamations, and conversions. There was no to a study of privatization commissioned by the orderly plan for restructuring.”13 Canadian Union of Public Employees, “[n]ot only are women as a group losing work that’s Nurses’ expressed concerns have included inad- full time and well-paid, immigrant, visible mi- equate levels of pay, job losses, understaffing, nority and Aboriginal women just getting a foot increased nursing workloads, increased levels of in the door are now fighting to keep the door stress, and “the steady erosion of “caring” as an from slamming shut altogether.”12 Health care essential service in health delivery.”14 Accord- job loss is also of particular concern to women ing to Glenda Doerksen, vice president of the living in rural and northern areas, as public sec- Manitoba Nurses Union, “Health Reform has tor jobs are often the best paid jobs for women not been a positive thing for front line direct in these communities. care providers. Even though we were the largest group affected by the changes, we were allowed no input into the process....Nurses feel devalued, C. WORKING CONDITIONS frustrated and exhausted. There is no longer any FOR WOMEN IN THE HEALTH time for the caring part of nursing or for patient teaching.”15 SECTOR In 1998, the Manitoba Nurses Union published Nurses and other hospital workers in Saskatche- Health Care in Manitoba: A Report from the wan and Manitoba have repeatedly raised con- Front Lines. This report contains first-hand ac- cerns over workloads, understaffing, and stress- counts by nurses, patients and the public of the ful working conditions within the health sector. impact of cuts to the health care system. More When the Saskatchewan Union of Nurses than 5,000 nurses, representing over 50% of the Manitoba Nurses Union’s membership, took (SUN) called a provincial strike in April 1999, it part in the Nurses Survey on Health Care. Eigh- was the latest in a series of actions designed to ty percent of nurses responding to the survey call attention to conditions of work in the health reported that their workload had increased since system. Within hours, the NDP government September 1995. Nearly half reported that they passed legislation ordering the nurses back to suffered from three or more symptoms of “burn- work. However, Saskatchewan nurses defied the out.” The report also cited evidence that the back-to-work legislation and refused to return to work until receiving a commitment that salary and workload issues, among others, would be 13 addressed. Larry LeMoal, “Nursing: In sickness or in health?” Spectrum, January 1998, p. 1. 14LeMoal, 1998, p. 2. 15Glenda Doerksen,“Providing Care” in Health Reform and 12Canadian Union of Public Employees, www.cupe.ca/ Women: Opportunities for Change,1999 Provincial Forum, doc/990114%2D7.html Winnipeg: Women’s Health Clinic, March 1999, p. 52.

Page 45 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan number of registered nurses leaving the prov- In 1996, the Manitoba Nurses Union produced ince has exceeded the numbers of new regis- an analysis of 2,000 Workload Staffing Reports trants, including new Manitoba graduates.16 filed in 1995/96. A Workload Staffing Report (WSR) is filed when a nurse believes that “the As management practices in the health system workload/staffing situation is such that adverse emphasize cost-effectiveness, some have argued effects regarding patient/resident well-being that the health care workforce is being de- may occur.”18 Documentation of WSRs in- skilled, with less-trained and lower-paid work- creased by 34% between 1993 and 1996. The ers taking over tasks and reducing the number of WSRs most frequently cite inadequate care and nurses. According to the Saskatchewan Union of monitoring of patients, inadequate time to pro- Nurses, “[s]ince 1993, ‘licensed providers’ in- vide psychological and emotional support to cluding RNs, RPNs and LPNs have lost 279.5 patients and families, and inadequate time for positions, while the number of health providers patient teaching as results of nursing workload in the aide category have increased by 153.5. and staffing problems.19 According to the report, (Within the aide category there has been a shift some of the contributing factors to this increase from nurses’ aides to more special care aides include: provincial funding cuts, bed closures, and home care aides.) Registered nurses, as a nursing lay-offs, as well as the de-skilling, “in- percentage of these six health providers, have tensification” and “casualization” of nursing la- declined to 45.3 from 46.7 percent.”17 On the bour. other hand, some health policy analysts predict that as health reform evolves, nurses will take Intensification, or speeding up, of nursing care on increasingly important roles in the health is a management practice which cuts costs by care system (e.g., as advanced clinical practitio- increasing nursing workloads and reducing ners in community health centres and other nursing staff levels. Intensification occurs as community-based services.) nurses are required to perform a target number of tasks, such as delivery of medications or In Manitoba, part of the health reform strategy monitoring vital signs, within a certain time was to commission a report on nursing staffing frame. Bed closures and shorter hospital stays from Connie Curran, an American-based health can contribute to intensification, since there is a care consultant. The report recommended sev- greater number of admissions and discharges to eral changes designed to lower expenditures on manage, and the patients in hospitals are those nursing staff by introducing private sector man- who require higher levels of care. Nurses report agement practices. One example of this is the that one of the results of intensification of their de-skilling of nursing providers, where tasks tasks is a loss of time for patient teaching and performed by a higher skill level nurse are providing emotional support for patients and transferred to lower skill level, and hence, lower their families.20 Patient teaching is especially paid, staff. This strategy resulted in the lay-offs critical when patients are being sent home more of many licensed practical nurses (LPNs) in the quickly after surgery. The provision of emo- Manitoba health care system, whose tasks were tional support to patients and their families is transferred to health care aides. important as social support is a known determinant of health.

16Manitoba Nurses’ Union, Health Care in Manitoba: A Report from the Front Lines; Winnipeg: Manitoba Nurses’ 18Manitoba Nurses’ Union, Documenting Nursing Workload: Union, 1998, p. 4. Workload and Staffing Report 1995/96, Manitoba Nurses’ 17Saskatchewan Union of Nurses, “How rationalization of Union: 1996, p. 1. health services is effecting nursing in Saskatchewan,” Spec- 19Ibid, p. 15. trum, January 1998, p. 7. 20Ibid, p. 12.

Page 46 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Casualization of nurses is also occurring in sector has had the highest rate of WCB injury Manitoba. Casualization means that there are rates in the province. Health care workers are more nurses hired on a casual basis, and fewer working short-staffed and under incredible full time, permanent nursing positions. Casual stress because of staffing cuts and non-replace- nurses provide services to different wards on an ment of workers on sick leave.” 22 intermittent basis, thereby affecting the continuity of care provided to patients. Table 9 illus- The shift from institutional to home care moves trates the shifts in employment classifications the locus of care work to the private household. for nurses in Manitoba during the time period How does this form of privatization affect that health reform was introduced. health care workers? What occupational hazards are associated with care given in private house- TABLE 9: MANITOBA NURSING STAFF BY holds? Increased acuity of home care, the use of EMPLOYMENT CLASSIFICATION 1992-1996 new medical technologies in the home, and the 1992 1993 1994 1995 1996 lack of readily available institutional supports Full have all been identified by home care staff as 39.7% 38.2% 37.2% 36.5% 34.7% Time factors affecting their work and the quality of Part care they are able to provide. A research project 43.0% 43.8% 43.1% 45.1% 46.4% Time funded by the Prairie Women’s Health Centre of Excellence is currently conducting a study of Casual 17.3% 18.0% 19.7% 18.4% 18.9% changes in home care services in one regional Manitoba Nurses’ Union, Documenting Nursing health district in Saskatchewan. The study is Workload: Workload and Staffing Report, 1995/96, p. 11. designed to examine how changes in the labour process affect home care workers in three different occupational groups.23 How do private, for-profit employers and private sector management practices affect work- There are many unexplored questions regarding ing conditions in the health sector? Are women the experiences of women in a variety of health particularly vulnerable to employer expectations occupations. What are the levels of pay, job se- that they do more with less? Health sector un- curity, hours of work, and conditions of work? ions have raised concerns about health care pri- Have part time and casual positions increased? vatization, public sector job losses, deteriorating What differences exist between private, for- working conditions and lower wages. Some ar- profit, and non-profit health care agencies? How gue that health management practices which do recent changes in the health system affect the emphasize cost-cutting are changing the pace health of health care providers? and organization of work. Some of these changes also pose a threat to health workers’ One Canadian study of private home care ser- health and safety. Hospital food services, for vices found significant gender and age differ- example, may come to resemble a fast-paced ences between the staff compositions of for- assembly line, thus increasing the potential for profit and non-profit agencies. Non-profit agen- job stress or occupational injuries, such as repet- itive strain disorders.21 According to CUPE Sas- katchewan, “[f]or several years, the health care 22Canadian Union of Public Employees, 1999, p. 6. 23Allison Williams, Women’s Formal (Paid) Home Care Work in Transition: The Impact of Reform on Labour Process 21Canadian Union of Public Employees, 1998, p. 6. Change in Saskatoon. (Research in progress).

Page 47 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

cies were more likely to employ older staff, es- provinces are based on the assumption that care pecially women, while for-profit agencies em- within the home is largely a family responsibil- ployed a larger proportion of younger men and ity. According to the Canadian Home Care As- part time younger females. “The prevalence of sociation, “The purpose of home care is to help younger part-time females in profit-making or- people who need acute, palliative and support- ganizations may or may not imply more flexibil- ive care to remain independent at home. It is in- ity in terms of job-sharing opportunities and less tended to supplement, but not replace, support possibility of “burn-out,” which could have fa- provided by the family and the community.”26 vourable implications for clients. Employment When government health reforms emphasize of older staff in the non-profit agencies could “partnerships with the community,” women are mean that clients are served by people with often the “partners” expected to provide more greater experience.”24 Further study into these care at home. Often they do so without suffi- differences, including examination of types of cient support services, such as respite and home work, levels of training and conditions of em- care services, or supportive policies, such as ployment, would be of interest. leave from paid employment.27

D. IMPACT ON INFORMAL Health reform in both provinces was designed to reduce health care delivery in institutional set- CAREGIVERS tings while offering home care and community- based services as an alternative. This shift, part- Women perform most of the unpaid caregiving ly driven by the desire to reduce expenditures, work in Manitoba and Saskatchewan. In 1996, also was intended to improve care receivers’ 188,475 Manitoba and Saskatchewan women quality of life and to encourage independent reported performing some hours of unpaid care living as long as possible. Reduced reliance on to seniors. Over thirty thousand women in the institutional care can have significant benefits, two provinces reported spending ten or more but reduced access to institutional care also can 25 hours per week on elder care. Wives, daugh- create tremendous pressure on families to pro- ters, and mothers provide the bulk of care to vide much of the care that would otherwise have family members who are ill or disabled. been provided by the health system. According to one Saskatchewan caregiver, “with health Under health reform, women’s caregiving roles reform it’s getting tougher and tougher to get within the family have been taken for granted people into [nursing] homes or hospitals or so and the private household has been defined as on. There’s a lot of pressure to keep them in the preferred locus of care for those with “light” their homes longer.”28 care needs. Home care policies in both

26Canadian Home Care Association, in collaboration with 24Daphne Nahmiash and Myrna Reis, An Exploratory Study l’Association des CLSC et des CHSLD du Québec, Portrait of Private Home Care Services in Canada, Ottawa: Health of Canada: An Overview of Public Home Care Programs Services Promotion Branch, Health Canada, 1992, p. 36. (draft), February 1998, p. 1. 25Statistics Canada, “Population 15 Years and Over in Private 27Women and Health Reform Working Group, Health Re- Households by Census Family Status, Presence of Children, form: Making it Work for Women, Winnipeg: Women’s Labour Force Activity and Sex, Showing Hours of Unpaid Health Clinic, 1997, p. 8. Care to Seniors, for Canada, Provinces and Territories,” 1996 28Living for Others: The Life Stories of Older Women in Census, www.statcan.ca/english/census96/mar17/house/ Saskatchewan, Video and Discussion Guide, Seniors table11/t11p46a.htm Education Centre, University of Regina, 1995.

Page 48 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

While some of the architects of health reform health system is taking advantage of them by acknowledge the possible impact on informal shifting care from paid workers without taking caregivers, they have made very little effort to responsibility for understanding and protecting monitor the impact. As people are kept out of the conditions under which the unpaid care- hospitals and long-term care facilities, women’s givers work.”32 carework in the home may intensify, but policy- makers remain largely unaware of the conse- Research on family caregivers has shown that quences of their decisions on women’s lives. caregiving can have significant negative effects According to the former Saskatchewan Deputy on the caregiver’s physical, emotional, financial Minister of Health, the reduced institutionaliza- and social well-being. Older caregivers have tion of the elderly combined with the sometimes reported increased stress, high blood pressure, inadequate level of home care support could be fatigue, exhaustion, and a greater susceptibility expected to have “a major impact on women, to physical illness.33 Caregivers are twice as but its nature, volume and effects have never likely to suffer from depression as non-care- been measured in Saskatchewan.”29 In a recent givers.34 While caregiving can be personally study of regional health planning in Manitoba satisfying, it can also lead to feelings of anger, and Saskatchewan, only one of twenty-three guilt, resentment, frustration, grief, depression, regional health plans included recognition that loneliness, and fear.35 In one Saskatchewan informal caregivers are more likely to be study, nearly half the caregivers reported that women than men.30 their health had deteriorated since they had begun caregiving. These caregivers reported in- In 1997, the International Centre for Unpaid creased depression, exhaustion, stress head- Work organized three public forums on unpaid aches, and back pain since assuming duties as work in Saskatchewan (in LaRonge, Saskatoon, informal caregivers.36 While many informal and Swift Current). One of the issues which caregivers choose to provide care and find the emerged at these forums was the impact of experience rewarding, lack of access to institu- health reform on the unpaid work of family tional care or adequate support services has left caregivers. Participants in the forums felt that some family members feeling trapped in roles as “health reform is shifting large amounts of la- “involuntary” caregivers.37 According to some bour to unpaid workers without properly sup- observers, “[health] reform will work only if porting or protecting them, and this is putting caregivers are connected to a network of ser- unpaid workers’ health and economic well-be- vices which are accessible, flexible, affordable ing at risk.”31 Participants in the forums ex- and responsive.”38 pressed a desire for, “more recognition that the majority of health care is done by family members at home, mostly women...[and that] the 32Lees, 1997, p. 9. 33National Advisory Council on Aging, cited in Living for Others Discussion Guide, p. 3. 34Cited in Living for Others Discussion Guide, p. 3. 29Duane Adams, personal communication, 1999. Used with 35Living for Others Discussion Guide, p. 3. permission. 36Bonnie Blakley and JoAnn Jaffe, Coping as a Rural Care- 30Tammy Horne, Lissa Donner and Wilfreda Thurston, giver: The Impact of Health Care Reforms on Rural Women Invisible Women: Gender and Health Planning in Manitoba Informal Caregivers, unpublished manuscript, 1999. and Saskatchewan and Models for Progress, Winnipeg: 37Comments made by participants at Winners and Losers: A Prairie Women’s Health Centre of Excellence, 1999, p. 39. Forum on Home Care, sponsored by the Saskatchewan 31Carol Lees, Forums on Unpaid Work, Saskatoon: Inter- Health Coalition, Saskatoon, March 6-7, 1998. national Centre on Unpaid Work, 1997, p. 8. 38Living for Others Discussion Guide, 1995, p. 5.

Page 49 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

The International Centre on Unpaid Work re- ilies with the ability to pay. Thus the privatiza- ported that caregivers in Saskatchewan were tion of responsibility for caregiving has differ- adversely affected by the rising expectations of ent consequences for those who can purchase the health care system and the lack of adequate support services, and those who cannot. protection and support. “Money, of course buys anything you need, if you have it. So if you have lots of money then Home based caregivers are providing ever it’s a moot point, because you can buy any ser- increasing amounts of care, at ever higher vice that you want to buy. If you don’t have levels, without adequate support services, money, you’re at the mercy of whatever system without payment, pensions, labour standards, you can find, negotiate and make work for insurance protection or workers’ compensa- you.”40 tion. Unpaid workers describe heavy work loads and excessive hours of work, insecurity, isolation, exhaustion and feelings of helpless- When caregivers voice their concerns over the ness. Pushing unpaid workers beyond their costs of accessing support services, they are ability to cope leads to stress and depression, sometimes met with an unresponsive system. increases their risk of mental or physical One caregiver reported that when she spoke breakdown, and reduces the quality of patient with a social worker about the costs of home care.39 care, she was told, “If you can’t afford home care for your husband, you could get a separa- Informal caregivers often face additional costs tion, or quit your job and go on welfare.”41 and financial burdens related to caregiving. When residents in one health region repeatedly These include payment of user fees for home expressed a desire for additional home care ser- care services, the cost of home adaptations, the vices in heavy housework and yard work, the purchase of equipment and supplies, fees for official response was a communications cam- respite care, transportation to medical appoint- paign to inform residents that such tasks were a ments, and direct medical expenses. These costs private responsibility.42 pose a financial barrier to women with limited financial resources. Older women on fixed in- In addition to direct costs, many caregivers ex- comes, and women living in poverty do not have perience reductions in income as they adjust the financial resources to access a range of their employment in order to fulfill their support services which would reduce their bur- caregiving responsibilities. According to the den of care. National Advisory Council on Aging, loss of income due to reduced or lost employment, For caregivers who can afford them, support foregone wages or opportunities for advance- services are available in some locations. For ment and reduced pensions resulting from others, the cost of such services or their distance caregiving responsibilities, have negative impli- reduces their accessibility. Support services are cations for the economic well-being of care- crucial to maintaining the well-being of the givers.43 A study of rural informal caregivers in caregiver, but only if they are affordable and Saskatchewan found that several women retired accessible. Some caregivers report that fees from paid employment because of the demands charged for home care services, adult day care and respite services restrict access to those fam- 40Living for Others video, 1995. 41Lees, 1997, p. 3. 42Horne, Donner and Thurston, 1999, p. 39. 39Lees, 1997, p. 9. 43Cited in Living for Others Discussion Guide, p. 3.

Page 50 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan of caregiving; and several reduced their hours of The HSURC study also used one-page logs for paid work in order to have time for their patients and caregivers to record their out-of- caregiving responsibilities.44 pocket expenditures and the time spent in caregiving. The time spent “keeping people A recent study by the Health Services Utiliza- company” was excluded from the calculations. tion and Research Commission (HSURC)45 While social support is widely recognized as a sought to determine whether the substitution of determinant of health, and friendly visits are home care for hospital care was truly a more listed as one of the services included in a com- cost-effective means of reaching the same prehensive home health care program, the time health outcomes, whether such home care repre- spent providing this service has apparently no sented an additional cost to the health system, value. and whether any apparent public cost savings were masking a transfer of costs to patients and The value of caregivers’ time was calculated at family caregivers. This study of acute home a replacement cost of $15 per hour based on the care as a substitute for longer hospital stays is estimated costs of hiring someone from a pri- one part of a larger study which will also exam- vate home support service agency. Caregivers in ine home care as a preventive service designed this study, which only focused on episodes of to reduce demand for institutional care, and post-acute care, donated an average of 1.5 hrs of home care as a substitute for long-term residen- caregiving services per day over the 30-day log- tial care. It is important to note that this study ging period. The average value of unpaid care- deals with home care following an episode of givers’ time was estimated to be $564 per 30- acute care, not long-term care of the chronically day period, with very little difference between ill or disabled. situations where patients received post-acute care in the hospital, received post-acute home The HSURC study used a Burden Interview ad- care services, or were discharged with no post- ministered to informal family caregivers two acute care. The average out-of-pocket expenses weeks after a patient’s acute care episode. While for caregivers and patients was $94 over the 30- the interview schedule covers some of the day logging period. The average costs to pa- potential impact, it has its limitations. For ex- tients and caregivers, including estimated values ample, the only question related to the financial for the caregivers’s time and out-of-pocket ex- burdens imposed on caregivers reads as follows: penses, were higher for patients who received “Do you feel that you don’t have enough money post-acute care in the hospital compared with to care for your relative, in addition to the rest those who did not. Similarly, the costs to pa- of your expenses?” Likewise, the impact of tients and caregivers were somewhat higher for combining caregiving, other family responsibili- those who received home care services, than for ties and paid employment are collapsed into one those who did not. item which reads: “Do you feel stressed between caring for your relative and trying to meet other While the HSURC study of home care costs in- responsibilities for your family or work?” cluded efforts to measure caregivers’ burden and costs, including the value of caregivers’ time and out-of-pocket expenditures, the data 44Blakley and Jaffe, 1999, pp. 117-118. were not presented in ways which allowed for 45Health Services Utilization and Research Commission any gender analysis. Beyond noting that 61% of (HSURC), Hospital and Home Care Study, Summary Report the caregivers who completed interviews were No. 10, Saskatoon: HSURC, 1998.

Page 51 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan female, there was no further discussion or anal- Those who provide care to family members, ysis of gender differences in hours of care or whose first language is not English, face greater measures of caregivers’ burden. Income infor- risk of isolation. In cross-cultural situations, mation gathered was based on household, rather service providers may not be able to communi- than personal income so it is impossible to mea- cate with the clients or be aware of diverse cul- sure any changes in women’s individual in- tural needs. Thus, caregivers are more reluctant comes, or their increased economic dependence to leave the care recipient in someone else’s on others, stemming from their assumption of care. As one caregiver pointed out, “even if you caregiving responsibilities. The caregivers’ bur- get some care, extra care, nobody could look den interview results have been reduced to nu- after her because of the language barriers.”47 merical scores used for comparing the level of burden between different groups of caregivers. Many caregivers experience a sense of accom- They provide no adequate description of the plishment and personal growth through their conditions which reduce or exacerbate the bur- role in a caregiving relationship. Some report dens of caregiving. that their lives are enriched by supportive individuals they have met within the health care The study found that self-reported levels of system, church, and community. However, caregivers’ burden were higher among care- some describe caregiving situations which un- givers who were between 45 to 59 years of age, dermine their own health and well-being, and go living with small children, in poorer health, car- beyond reasonable expectations of family care. ing for a parent, or caring for a person with A single mother with a chronically ill child de- lower physical or mental health scores. Care- scribed her caregiving situation in rural Sas- givers’ burden scores and levels of satisfaction katchewan: with services were very similar regardless of whether or not the patient received post-acute I do daily the work of three shifts of nurses in care in the hospital, and whether or not they re- a hospital setting: I administer 10 hours of ceived post-acute home care services. Given the peritoneal dialysis six day per week. I prepare similarity in physical health outcomes, as well charts which are reviewed by doctors. I dis- as measures of patient and caregivers’ costs and pense medications around the clock. I change satisfaction with services, HSURC concluded surgical dressings. I oversee daily vomiting that it makes sense to opt for the less expensive sessions. I attend all bathroom visits because alternatives to hospital-based post-acute care. of immobility due to renal osteoporosis. I hand feed one meal per day because of renal anorexia. I order medical supplies. I do daily The time demands of caregiving and a lack of the work of a hospital orderly: I lift a 46- family and community supports can reduce op- pound child countless times. I lift her wheel- portunities for caregivers to engage in social chair as well as one very heavy bucket of dial- activities. In a study based on interviews with ysis effluent daily. I transport and lift 60 rural informal caregivers in Saskatchewan, the boxes per month of dialysis fluid. I have the majority of respondents were dissatisfied with physiotherapy exercises to oversee daily for their level of social activities and attributed their strengthening leg muscles. I have the respon- lack of social participation to the time and en- sibility of a doctor, with my patient’s life liter- ergy required to provide care.46 ally in my hands on a daily basis; one wrong

46Blakley and Jaffe, 1999, p. 115. 47Living for Others video, 1995.

Page 52 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

gesture on my part with the dialysis tubing toba reported that she needed to provide daily and she runs the risk of fatal infection. All care for a family member while he was hospital- these responsibilities are well over and above ized. “I spent every day for three months with the task of responsible motherhood and I my husband in hospital because I did not feel he firmly believe they must be paid for....[I] am would get good care if I left even for one day. currently expected by the medical and social When he was too sick or sedated to answer for institutions to be “on duty” 24 hours per day himself, who knows what would have happened with no days off, no vacations and no bene- 49 fits.48 to him.”

This caregiver described a number of conse- A recent study of rural women informal care- quences of the health system’s expectation that givers was funded by the Prairie Women’s she perform the duties of a skilled health care Health Centre of Excellence. The study ex- provider 24 hours per day: social isolation, loss plored the impact of health reforms on care- of paid employment, poverty, dependence on givers in a rural health district in Saskatchewan, social assistance, physical and emotional strain. and examined the ways in which the impact was She has argued that the current expectations that further magnified by the lack of formal and in- she provide these services free of charge is a formal supports in the region. The study re- violation of her human rights, and she has asked vealed that caregivers were leaving paid em- that she be paid by the health district for the ployment or adjusting their paid work to accom- health care services she provides. Calculating modate their caregiving responsibilities, that the time during which she is performing the du- caregivers were reducing their participation in ties of a health care provider as 312 hours per social activities as a result of caregiving, that a month at an estimated value of $20 per hour, she majority of those interviewed reported that their argues that the health district should be paying health had worsened, and that rural communities her $6,240 per month for the specialized health faced particular challenges which health service 50 care services she provides to her child. Her providers needed to take into account. claim has drawn the attention of feminist aca- Other research on women’s caregiving is cur- demics and human rights activists at the Univer- rently underway. Karen Grant, Barb Payne and sity of Regina and the University of Saskatche- David Gregory have received funding from the wan who have assisted her in presenting her Social Sciences and Humanities Research Coun- claim to members of the provincial government. cil (SSHRC) for a three-year project entitled, “Women’s Caring Work in the Context of Mani- While informal caregiving is often assumed to toba Health Reform.” Interviews will include take place within the home, family caregivers paid and unpaid female caregivers and are de- also report that they provide necessary care to signed to solicit information about health reform family and friends within institutions. The level and the labour process, as well as the health and of informal caregiving within health care insti- well-being of women engaged in unpaid 51 tutions has not been monitored, although anec- caregiving. dotal evidence suggests that family members take over tasks which paid health care providers do not have time to perform. A woman in Mani- 49Manitoba Nurses’ Union, 1998, www.nursesunion.mb.ca/ report/graphs15.htm 50Blakley and Jaffe, 1999. 51Karen Grant, personal communication, March 1999. Used 48Lees, 1997, p. 4. with permission.

Page 53 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

The Prairie Women’s Health Centre of Excel- During the 1990s, the proportion of health care lence is currently funding two other research expenditures paid by individuals or private projects which look at the health of informal health insurance has increased. Many women caregivers. One study, based on interviews with may face financial barriers to accessing health caregivers in Saskatchewan, looks at the effects services which are not fully covered by Medi- of health reform, deinstitutionalization, and care. Women, because of their lower incomes, caregiving on the health of informal caregivers their greater risk of poverty, and their lack of who provide long-term care for persons who are access to employment-based health insurance chronically or terminally ill, disabled or elderly. coverage, may be disproportionately affected by The other research project, using data from the the privatization of health care costs. Many sin- Manitoba Study of Health and Aging, focuses gle mothers, women with disabilities, Aborigi- on the relationship between gender, employment nal women and senior women live well below status, home care service use, and the health of the poverty line. User fees for health care ser- caregivers. vices would be especially damaging to low in- The Prairie Women’s Health Centre of Excel- come women who have high health care needs. lence has also awarded a developmental grant to the Peepeekisis First Nation in Saskatchewan. Under the pressure to contain public expendi- The project will examine the issues facing on- tures on health, governments have shifted some reserve women who care for multi-generational of the responsibility for payment to individual families. The combination of caring for more users of services. Private expenditures for some than two generations of family, living in a rural health services have increased, though targeted community with little or no support services to public programs provide coverage to some low ease the burden, often compounded by employ- income people. Combined public/private payment outside the home, presents significant ment schemes apply to prescription drugs, den- stressors which have the potential to affect the tal, eye care services and other supplemental overall health and well-being of on-reserve health services. While programs of targeted fi- women. nancial coverage of health expenses reduce financial barriers and provide access for some, E. IMPACT ON WOMEN AS they are not without problems. A participatory CARE RECEIVERS action research project on poverty and health in Saskatoon revealed that some low income per- We found very little research in Manitoba or sons felt they were subjected to second-class Saskatchewan which focused on women’s expe- treatment because their health cards identified riences of health reform as patients or users of them as social assistance recipients. On the health services. A recent study of community other hand, low income residents who did not health needs assessments and health plans re- qualify for drug coverage or supplemental vealed that many regional health bodies in Man- health coverage, felt that their access was re- itoba and Saskatchewan did not disaggregate stricted by their inability to pay.53 In addition, data by sex and were thus limited in their ability targeted programs, in contrast to universal pro- to identify the health needs of women in their grams, run the risk of losing support from mem- regions.52

53Personal Aspects of Poverty Group, Poverty, People, Par- 52Horne, Donner and Thurston, 1999, p. 33. ticipation, Saskatoon, 1995, p. 32.

Page 54 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan bers of the public who are not eligible for bene- The refusal of the Manitoba government to fits. Private, for-profit health service providers cover abortions provided in a private clinic, de- can be hired to provide home or in-hospital care spite introducing a legislative framework to for patients who will pay the fees. As the num- cover other surgical procedures in private clin- ber of nurses have decreased in hospitals, some ics, is an example of a differential impact of families are opting for this high-priced alterna- privatization on women as care recipients. tive to supplement care. Costs for these services can amount to $100 per day.54 Women may find In Manitoba, there have consistently been wait- themselves in a variety of situations where their ing lists for personal care home beds. At the access to some health services is mediated by same time as more than 1,200 acute care beds their income and their access to public or pri- were being closed in Manitoba, 436 new per- vate health coverage. sonal care home beds were created with the intention of moving people from more expensive We found little research related to health care acute care to less expensive personal care privatization and women’s access to reproduc- homes. All residents of licensed personal care tive health services. In both Manitoba and Sas- homes are assessed a daily residential charge. A katchewan, the recent passage of midwifery leg- sliding scale of rates based on income is estab- islation could expand the range of choices in lished by Government and the charge is reas- prenatal, birthing, and postpartum care. How- sessed effective August 1st each year. Effective ever, in Saskatchewan, there has been no com- August 1, 1997, the minimum rate was in- mitment to include midwifery services under the creased to $24.80 per day and the maximum public health insurance program. Without public was increased to $57.90 per day.56 The maxi- financing of midwives’ services, this kind of mum has since increased to $58.40 per day. An care may be inaccessible to those unable to pay. amendment to the Manitoba Hospital Services A recent study of women’s experiences of mid- Insurance and Administration Regulation passed wifery care found that midwifery clients valued on October 16, 1998 allows these per diem the time midwives spent with them, the person- charges to be applied to persons in hospital alized care and support, and the holistic, unob- awaiting beds in personal care homes. If a per- trusive, low-tech style of care provided. Partici- sonal care home bed has become available and pants in the study recommended that midwifery an individual refuses to accept it, hospitals are services be publicly-funded in order to be acces- able to charge the full per diem cost for a hospi- sible to all women regardless of economic sta- tal bed.57 According to Manitoba Health Annual tus.55 Reports from 1989 to 1997, home care clients in Manitoba have increased by 23% over that Women in Manitoba seeking abortions are faced eight-year period.58 Women make up a greater with the options of four to six week wait times proportion of home care recipients. or paying up to $550 at the Morgentaler Clinic.

56Manitoba Health, Annual Report 1997-1998, www.gov.mb. 54Manitoba NDP News Release, “Two-tier health system ca/health/ann/199798/4abcdefg.html#Personal Care Home evident in Westman,” March 17, 1998. Program 55Meaghan Moon, Lorna Breitkreuz, Cathy Ellis and Cindy 57Manitoba Gazette, Vol. 127, No. 42, p. 394. Hanson, Midwifery Care: Women’s Experiences, Hopes and 58Manitoba Health, Annual Reports 1989/90 to 1996/97, Reflections, unpublished manuscript,1999. Manitoba Health, 1990-1997.

Page 55 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

In Saskatchewan, many older women who, in Women receiving care at home may experience the past, would have received care in publicly- social isolation, increased dependence on family funded Level 1 and Level 2 long-term care facil- members, feelings of being a burden, inadequate ities, are now living at home or in private per- or unskilled care, neglect or abuse. sonal care homes. The policy shift from institutional care toward more home and community Family care of older women occurs within a care could be having a number of benefits for cultural context which marginalizes older senior women who are able to maintain their women and places a high value on individuals independence and live at home. Home care may who are independent and self-reliant. Does the offer them some of the support needed to re- high value placed on independence and the ex- main in familiar surroundings, close to family pectation of family care create barriers to senior and friends, with access to health services pro- women seeking support and care from other vided at or near home. However, this major shift sources? What happens to senior women who in care options for senior women should be need more care than home care services and monitored to ensure that residents of personal their family members are able or willing to pro- care homes have access to high quality care, and vide? The needs of dependent aging women that women living independently receive the may be given lower priority than competing necessary supports to remain healthy at home. caregivers’ obligations to jobs, spouses, and Reduced access to institutional care could mean children. In Canadian society, older women are reduced access to health services, unless an ade- often culturally devalued and portrayed as a bur- quate system of community-based support ser- den to their families and society at large, thus vices has been developed. diminishing their sense of entitlement. The expectation that care is a private family responsi- The policy of reducing hospitalization through bility may make them reluctant to make de- outpatient surgery and earlier discharge has in- mands on public services: creased the number of home care patients receiving post-acute care. Some health care pro- These cultural assumptions and material reali- viders have raised concerns that shifting post- ties work to sustain the existing pattern of acute care to delivery within private households care, keeping the major portion of responsibil- is changing the nature of home care toward a ity outside the public realm and outside the more medicalized model. According to the concerns of men. However,...sustaining this Manitoba Nurses’ Union Survey, 79% of nurses pattern comes at a high cost to women; it in- in Manitoba reported that patient teaching is troduces contradictions and strains into their neglected.59 The lack of appropriate patient edu- lives that stifle and suppress their pursuit of cation can lead to additional problems when need-meeting behaviour and opportunities for patients are discharged soon after surgical pro- self-enhancement….Recognizing the ways in cedures, as patients may not know how to care which the existing pattern of care constrains for wounds. women and works to their detriment over the life course, the challenge for the future is to The overwhelming majority of elder care in render thinkable other societal responses to Canada is provided by family members in the old people’s needs that do not operate at the home. Many people express preferences for this expense of women….For women to identify type of care yet some older women may not be their needs and wishes and translate them into action, not only would they require an array of well-served by a privatized pattern of care. available supportive services, but also a breaking down of these ideological barriers to using them….Reduction of these ideological 59Manitoba Nurses’ Union, p. 13. constraints must be accompanied by the de-

Page 56 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

velopment of alternative public responses to A research project funded by the Prairie women’s concerns that enhance their inde- Women’s Health Centre of Excellence is cur- pendence and security over the life course. rently examining the health practices of senior Working toward such changes in the concep- women living in the community.62 By inter- tualization of social policies and practices can contribute to freeing women to express their viewing women and working closely with those needs and pursue solutions to them without who provide housing and support services to the spectre of guilt and shame to which they seniors, this study will examine the effects of are presently subject.60 current policies and assumptions about public obligations and private responsibilities for the The Maritime Centre of Excellence for health of older women living in the community. Women’s Health also has called for a gender analysis of home care policies in order to deter- Another research project funded by the Prairie mine whether they place women at a disadvan- Women’s Health Centre of Excellence exam- tage. The Centre argues that it is important to ined the problem of social isolation and loneli- determine whether, “assessments of needs and ness among senior women in Manitoba.63 Using resource allocations in care situations carry sys- personal interview and administrative data from temic biases by implicitly accepting women’s role as unpaid informal caregivers and overesti- the 1996 Aging in Manitoba Study, the re- mating the ability of elderly women to care for searchers found that older women were more themselves?”61 likely than men to be widowed and more likely to live alone. Fifty percent of the women, and The rhetoric of health reform certainly promised 39% of the men reported the highest levels of that home and community-based health services loneliness. This raises concerns regarding the would be enhanced, but more detailed monitor- adequacy of community-based supports for ing of the changes in services would be required older women living in their own homes. Social to assess how well those promises have been isolation and loneliness may be exacerbated by kept. A study of home care services should lack of income, lack of transportation, and poor monitor whether resources have been diverted health. from the health maintenance and home support services which were seen as central to home The Saskatchewan Health Services Utilization care in the past. Because services are delivered and Research Commission has received funding on a regional basis, and may vary across re- to conduct an investigation of the benefits of gions, it is difficult to determine whether the providing non-medical home care to seniors. support services needed by older women who Although the study does not focus on women, wish to remain in their own homes have become hopefully the analysis of the data will shed light more or less accessible. on the effectiveness of home care services in promoting health, independence and amount of 60Jane Aronson, “Women’s Perspectives on Informal Care of medical treatment required. the Elderly: Public Ideology and Personal Experience of Giv- ing and Receiving Care” in Health and Canadian Society: Sociological Perspectives, edited by David Coburn, Carl D’Arcy and George Torrance, Toronto: University of Toronto 62Katherine Ash, Health Practices of Community Living Press,1998, pp. 412-413. Senior Women (Research in progress). 61Maritime Centre of Excellence for Women’s Health, Home 63Madelyn Hall and Betty Havens, The Effect of Social Care and Policy: Bringing Gender into Focus, Discussion Isolation and Loneliness on the Health of Older Women, Series Paper No. 1, March,1998, p. 5. unpublished manuscript, 1999.

Page 57 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

F. SUMMARY OF IMPACT The transfer of care for patients from institutions to the “community” is a form of privatiz- ON WOMEN ing the provision of health care services that affects women as care providers and care recipi- It is clear that the privatization of health care ents. To some degree, the health reform policy services affects women in their many roles and of deinstitutionalization is founded on the on a variety of levels. While there has been very assumption that women will continue in their little research on the impact, we know from the traditional gender roles as caregivers. This existing literature that women comprise the ma- assumption is not articulated in health reform jority of health care workers, health care recipi- documents, but it would be impossible to pro- ents, and unpaid caregivers. Therefore, any vide care in the community unless women were changes to health care policy and practice will willing to do this work. In many cases, it may be affect women disproportionately. The funda- preferable for people to receive care in their mentals of gender analysis tell us that because homes, but those who provide the care must of women’s lower social status, the effects of receive adequate support so that they are not policies and practices may be experienced dif- penalized financially for their efforts. It is also ferently, and in some cases, more acutely by critical that the health of unpaid caregivers is women than men. protected. Serving in a traditional caregiving role may mean that women requiring care them- Privatization of health care has resulted in the selves are reluctant to ask for what they need. loss of good jobs for women who comprise the Who cares for the caregivers? majority of health care workers. In some cases, this has meant a direct loss of well-paying, The privatization of health care costs and the unionized jobs as parts of the health care system privatization of health care delivery may affect are transferred to private corporate control. For women who use health care services in a variety nurses in both Manitoba and Saskatchewan, the of ways. However, the lack of gender analysis in adoption of private sector management strate- research on health reform makes it difficult to gies in order to save money on hospital expendi- know which women are benefiting and which tures has led to reports of a serious decline in are being harmed. Differences of culture, socio- working conditions. economic status, income, occupation, region, and age are just some of the factors which need to be taken into account, along with gender, in assessing the impact of health reform policies on women using the health care system.

Page 58 PART 4 CONCLUSION

In Saskatchewan and Manitoba, health care pri- sulted in a shift of responsibility for the costs of vatization has taken several forms. In some health care to the individual, as well as the pro- cases, the privatization of health care is quite vision of these services to for-profit companies visible and overt. In other cases, the erosion of and unpaid caregivers. While privatization was public responsibility for health care is less obvi- not an explicit goal of health reform in Mani- ous. This report provides an overview of some toba and Saskatchewan, it appears to have been of the forms of health care privatization which one of the results. have emerged in recent years, and raises questions about the impact of those changes on Most health services and programs in Manitoba women. Figuring out what is happening in the and Saskatchewan are provided as publicly-in- health care system is not an easy task. The sured services, without additional fees charged health system is complex, multilayered, and to patients. However, many people pay privately constantly changing. The rhetoric of health re- for prescription drugs, dental care, optometric form, at times, seems to mask or contradict the services, complementary medicines, treatments reality. by non-physicians, long-term care, and some home care services. Since 1990, public expendi- In Manitoba and Saskatchewan, reforms to the tures as a proportion of total health spending health care system have occurred in an environ- have declined and private health expenditures ment of decreasing federal and provincial public have risen substantially. There have been spending on social programs. Over the last de- changes to provincial prescription drug plans cade, provincial governments have tried to make and provincial public health insurance plans the health care system more effective at improv- have de-listed or excluded some important ing health status, and more efficient at spending health services. The shift from institutional to resources to accomplish that goal. In an attempt community-based care also has resulted in a to spend less public money on health services, transfer of costs to the individual, as supplies provincial governments in Manitoba and Sas- and services, provided at public expense to hos- katchewan have allowed a creeping privatiza- pitalized patients, are no longer covered for out- tion in various parts of the health care system. patients. Private health insurance programs have Health reform policy strategies, such as regional expanded to fill the gaps in public coverage, but governance and the transfer of care from institu- private insurance is not accessible to all. tions to the home and “community,” have re-

Page 59 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

In addition to the costs of health services, the Health care in Manitoba and Saskatchewan also delivery of health services has been privatized in has been privatized in the sense that care work a number of ways, although the patterns vary has been transferred from institutions to private somewhat in the two provinces. Examples of households. In Saskatchewan, many small rural privatization include the elimination of the hospitals were closed or converted to commu- school-based dental program, the contracting nity health centres and public funding for light out of food and cleaning services in hospitals to levels of institutional care was eliminated. private, for-profit companies, the use of private, Home care services have increased and the for-profit medical laboratories, the expansion of number of institutional beds in both hospitals private personal care homes, and the privatiza- and nursing homes has declined. Privatization tion of home care services. In the cases of abor- has crept into many areas of the health care sys- tion and physiotherapy, private options exist in tem, especially as more care has shifted out of part due to long wait times for public services. institutions and into the home and community. While some government policies and regional health decisions have opened the doors to fur- A. IMPACT ON WOMEN: ther privatization in the health sector, other policies have attempted to place limits on the privat- MISSING LINKS ization of health care. The debate over the scope of public responsibility for health care contin- Women, to a greater extent than men, utilize the ues. health care system to access services for themselves and other family members. Women are There have been three major attempts at privat- the majority of workers in several health care ization involving for-profit companies in Mani- occupations, and women provide most of the toba: Home Care (Olsten Corporation); the unpaid, informal health care within the home. Manitoba Health Information Network (EDS, Women earn less than men, are more likely to Inc. and SmartHealth, a subsidiary of the Royal live in poverty, and are less likely to have pri- Bank of Canada); and the Urban Shared Ser- vate health insurance. Privatization in the health vices Corporation Food Services (Aramark). In care system can be expected to have significant each case, the government cited cost-effective- impact on women as users of health services, as ness as a primary motivator for securing private health care workers, and as informal caregivers. services. In each case, opponents of privatization were able to demonstrate that cost savings Health care policies and programs in Manitoba were negligible. In the case of home care, the and Saskatchewan are rarely informed by a gen- Minister of Health eventually concluded that the der analysis. There have been very few studies public system was a more cost-effective alterna- which focus on the impact of health care privat- tive than private sector care. The Manitoba gov- ization on women. Nevertheless, several impor- ernment ended its deal with SmartHealth in tant impacts on female health care workers were 1998, without having achieved the major goals identified including job losses, increased work- of the health information project. In each of loads, and stressful working conditions. Such these attempts to shift control of large sectors of impact poses threats to the physical and emo- the health care system to private, for-profit cor- tional health of women working in the health porations, American companies became in- care system and make it difficult for them to volved in the deal by purchasing interests in the provide high quality care. participating for-profit corporations.

Page 60 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

The privatization of heath care expenditures, in women’s needs.1 The Women and Health Re- all likelihood, has created financial barriers form Working Group (WHRWG) was formed in which affect women’s access to services, yet Manitoba in January 1996. Organizational mem- very little is known about the impact of privat- bers of the group have included the Manitoba ization on women as users of health services. Women’s Institute, the Manitoba Women’s Ad- According to health care workers, efforts to con- visory Council, the U.N. Platform for Action trol health expenditures have created staff short- Committee, the Provincial Council of Women, ages which have affected the quality of care, the Women’s Health Clinic and the Prairie patient safety and patient education. The health Women’s Health Centre of Excellence. The system’s assumption that family members are group has organized outreach workshops in available and able to provide care also may Dauphin and Thompson to discuss regionaliza- leave some women vulnerable to inadequate or tion and health reform with women. The group inappropriate levels of care, particularly as more continues to meet monthly, providing a forum complex caregiving tasks are being transferred for women’s health researchers, advocates and to the home. policy-makers to meet and share information.2 The group has met with Manitoba Health and The shift from institutional to community and staff of the Winnipeg Hospital Authority and the home care has created new demands on infor- Winnipeg Community and Long-term Care Au- mal caregivers. The studies of caregivers iden- thority to discuss women’s experiences with the tify impacts which include feelings of isolation, health care system, in areas such as mental unrelenting demands on their time, lack of health, home care and health planning. In March choices, loss of employment income, reduced 1999, the group organized a conference on social participation, and declining health. These Women and Health Reform that attracted over studies point to the need to develop policies one hundred participants.3 which will promote the well-being of care providers and increase their participation in the de- Nurses unions in both provinces have taken ac- cisions which affect them. tion to bring nurses’ perspectives on health reform to the attention of the public and policy- B. WOMEN IN ACTION: makers. In the spring of 1999, the Saskatchewan Union of Nurses went on strike demanding a RESPONDING TO HEALTH collective agreement which would address their REFORM concerns over wages, workloads, working conditions, and staffing practices. Within hours, the Some women have been voicing their concerns government of Saskatchewan introduced legisla- about health reform and some have been orga- tion to force the nurses back to work. The nizing to develop health policies more respon- nurses, however, refused to comply and contin- sive to women’s health needs. In 1996, the ued the strike until some of their concerns over Women’s Health Clinic in Winnipeg published wages and working conditions were addressed. an article entitled, “Health Care Reform and Regionalization: Can Women’s Voices Be Heard?” in which women were urged to seek 1 Women’s Health Clinic, Womanly Times, Spring 1996. opportunities arising from regional restructuring 2Women and Health Reform Working Group, Health Reform: to advocate for services which would address Making it Work for Women, Winnipeg: Women’s Health Clinic, 1997, pp. i-iv. 3Health Reform and Women: Opportunities for Change. Proceedings of the 1999 Provincial Forum, Winnipeg, March 1999.

Page 61 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Women employed in the health care system of- ticipate in decision-making regarding care and ten address their work-related issues through the new directions in health reform which effect participation in labour unions and professional their lives. Other recommendations include en- organizations. Health care workers in the Cana- hanced community programs, support groups, dian Union of Public Employees (CUPE) are respite services, more flexible adult daycare participating as part of a national campaign to programs, and emergency support for care- oppose privatization of public services. CUPE givers. Through the video and the Discussion Saskatchewan has developed a policy paper on Guide caregiving is presented as a valuable and privatization of health care which was brought important activity which must be a shared re- before their annual convention in 1999. CUPE sponsibility of men and women, families, com- Saskatchewan adopted an action plan for munities and government. The video challenges 1999/2000 which included plans to lobby the the assumption that caregiving is solely government for expanded home care coverage women’s work and argues that families, com- under the provincial health insurance plan, pre- munities, government, churches and the private scription drug coverage for home care patients, sector must share responsibility for caregiving. increased public funding to address staffing lev- Caregivers also identified the need for public els in health care, and public funding for light policies to offset the financial cost of caregiv- levels of care in nursing homes. The plan also ing.5 Some of these concerns are being ad- urged the adoption of community clinic models dressed through reduced home care fees, more of care with salaried physicians rather than fee respite beds and additional day programs to pro- for service. vide more relief to family caregivers, better access to information, rehabilitation services and Public sector unions, such as CUPE, the Na- mental health counselling services.6 tional Union of Public Government Employees, and the Manitoba Government Employees Un- While the video Living for Others is the result ion have been vocal opponents of privatization of a collective effort to bring the voices of care- because their members stand to lose well-paid givers into the discussions of health reform, in- jobs. In Saskatchewan, CUPE was successful in dividual action also has been an avenue used by several of their efforts to oppose privatization women to influence health policies. In Saskatch- through contracting out food, housekeeping and ewan, an individual woman providing care to laboratory services.4 her disabled daughter has been seeking recognition that current health policies are based on A group of caregivers in Saskatchewan worked unfair expectations and demands on family with the Seniors’ Education Centre at the Uni- members. Maureen Stefaniuk has written to versity of Regina to produce a video entitled, government representatives a number of times, Living for Others. The video documents many outlining her individual circumstances as a sin- of the problems experienced by informal care- gle mother providing skilled care to her disabled givers and has been used to stimulate further daughter. Stefaniuk has argued that, as a result public discussion of caregivers’ issues and con- of the government’s expectations of caregiving, cerns. The Discussion Guide which accompa- she cannot work outside the home for pay and nies the video recommends that caregivers’ par-

5Living for Others Discussion Guide, 1995. 4Canadian Union of Public Employees, 1999, pp. 7-8. 6Ibid.

Page 62 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

has been forced to rely on social assistance. TO: Suzanne Murray, Chair of Health, Social Stefaniuk has argued further that current health Policy and Justice Caucus Committee, MLA care policies constitute a violation of her human for Regina Qu’Appelle Valley; Violet rights. In response to her detailed description of Stanger, MLA for Lloydminster; Hon. Judy the complex, stressful and health-threatening Junor, Associate Minister of Health; Hon. Harry Van Mulligen, Minister of Social work she is expected to perform, she received a Services letter from former Health Minister Eric Cline, in which he reiterated the government’s commit- FROM: Ailsa Watkinson, Faculty of Social Work at ment to family-based care and rejected her re- University of Regina; Glenis Joyce, Women’s Studies in Extension at University of Sas- quest for financial compensation by saying, katchewan “Saskatchewan Health does not pay people in these circumstances for caring for family mem- DATE: December 17, 1998 bers.” Her case has received attention from two feminist human rights advocates in Saskatoon, Thank you for giving us the time to share the details of the day to day life of Maureen Stefaniuk and her who met with the NDP Health, Social Policy daughter Ilara. In our discussion we stressed that the and Justice Caucus Committee. A letter regard- situation faced by Maureen needs to be seen in the ing this case is offered opposite. context of women’s lives, the valuing of women’s work, the downloading of health care on families, The response from the government to the meet- primarily women, and our human rights obligations. ing, this letter, and subsequent phone calls was a Women like Maureen bear the brunt of health re- letter to Ms. Stefaniuk five months later. It of- forms in that caring is passed onto them. The burden fered no action or promises.7 is especially onerous as Maureen is a single parent and Ilara is disabled.

C. FUTURE DIRECTIONS FOR We requested that Maureen and others in similar situations be compensated through a wage for the ex- RESEARCH ON WOMEN traordinary work they do. Your initial response was to AND HEALTH REFORM focus first on improving Maureen’s immediate situation. It is our understanding that you will contact Maureen and, through the efforts of ministerial Women are disproportionately affected by changes in assistants in health and social services, work out a health policy because women comprise the majority more effective way to support her and her daughter. of paid workers, care recipients and unpaid workers in the health care system. Without gender sensitive We understand that our request that Maureen and research, the effects of changes in health care policy others in her situation be compensated through a cannot be adequately measured. Researchers have wage, is one your committee has heard before. We given little attention to the impact of health care pri- also understand that it is something you are giving vatization or health care reform on women. Policies thought to, since we did talk about the fact that which increase private responsibility for health care Maureen’s work (and the work of others) saves the government money. expenditures, encourage private health service delivery, and shift care to the private household are not We appreciated your interest and frankness. We urge gender neutral. A thorough assessment of the impact you to take timely action to lessen the burden this of health care privatization on women is needed. family and others are experiencing when faced with the daunting and exhausting task of providing health care for family members. We would be pleased to work with you on this issue in any way we can. Best 7Ailsa Watkinson and Glenis Joyce, personal communication, wishes in 1999 to all of you. 1999. Used with permission.

Page 63 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Given the lack of systematic research on the im- and economic dependency of an informal care- pact of health reform on women’s lives, it is im- giver and a society which privatizes, devalues, portant that the Centres of Excellence and other and assigns caregiving work to women. health research organizations support further work in this area. There are a number of unan- It is also, as Aronson8 points out, important to swered questions about privatization, its various locate studies of women and health reform with- aspects, and their effects on women in diverse in a cultural or ideological landscape which de- social locations. While analyzing sex-disaggre- fines the scope of public and private responsibil- gated data is part of the solution, it is important ity for health and care and often equates to know which data to gather, and to place it caregiving with ‘women’s work’ or a ‘labour of within a conceptual framework which actually love.’ Only by clearly articulating those under- captures the social conditions which play a ma- lying cultural assumptions can we examine their jor role in determining women’s health. Re- consequences and consider alternatives. search studies must be designed to let us hear women’s voices describing their experiences, Part of the research on women and health care naming the barriers they encounter, and defining privatization must involve asking women to de- the solutions which will meet their needs. We scribe their experiences and the conditions also need qualitative and quantitative studies which affect their health and well-being. which enable us to define the broad patterns of Women’s perceptions of the health system must women’s experiences so that policies can ad- be a part of the knowledge used to inform health dress the needs of those groups of women policies. Women’s voices are needed to describe whose health is most at risk. the conditions in their homes and workplaces, to identify the barriers to their health and well-be- It is important that studies of the impact of ing, to shape health policies which address their health reform on women pay attention to the concerns, and to design a health system more broad social context and the major policy direc- responsive to their needs. At the same time, it is tions influencing government and institutional important to recognize that women’s voices decisions. When the social environmental con- have often been discounted, that richly detailed text is included in studies of caregivers, it is descriptions of experiences with the health sys- sometimes limited to the immediate household tem have been dismissed as “merely anecdotal” environment and the presence or absence of al- and that policy-makers ask for “hard” evidence ternative caregivers. What is left out of the pic- to inform their decisions. Research on women ture are the social, economic and health care and health reform therefore must draw upon a systems which structure the circumstances and variety of methodologies and recognize the conditions within which caregivers find them- value of diverse voices in the process of knowl- selves. Without identifying the features of these edge generation. systems, it will be impossible to develop social policies which can transform those systems to In the process of developing this paper, several create more appropriate, health-supporting envi- research questions emerged, which we were not ronments for caregiving. Links need to be made able to pursue given time constraints. They are between the problems encountered by individual offered here as a first step toward the construc- women, and the broader political economic tion of a gender sensitive research agenda on forces shaping those experiences. We need to health reform. make the links between biography and history, personal troubles and public issues, the isolation 8Jane Aronson, 1998.

Page 64

MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan e. What health services are provided by unpaid e. How are male and female care receivers af- family members or informal caregivers? fected by the shift to home and community care in terms of access to services, quality of f. What is the gender division of labour in each care, and continuity of care? of the above categories and how have patterns of employment and unemployment f. How are women participating, or not partici- changed over time? pating, in the decisions regarding the scope and nature of publicly-funded, publicly-pro- g. Among health care workers, how are various vided home care services? groups of women affected by health system restructuring in terms of employment oppor- g. Do women’s organizations have policy posi- tunities and quality of work life? tions or recommendations regarding health care reform? h. What is the impact of health reform on women of colour and immigrant women h. How have health reforms addressed working in the health system? women’s health needs or affected access to women-centred care, particularly in northern i. What are the levels of pay and benefits, con- and rural areas? ditions of work, levels of unionization for women working in each of the above catego- 5. Public Sector Cost Control Strategies ries? Which Mirror Private Sector Manage- ment Practices j. To what extent does the health system rein- force traditional gender ideology with expec- a. To what extent are health sector employers tations of informal caregiving, and at what reducing budgets by reducing staff or reallo- costs to women? cating tasks to lower paid health care workers? 4. Institutional Care/Home and Community Care b. To what extent are health sector employers increasing workloads and intensifying la- a. What are the trends in delivery of health ser- bour? vices in institutional versus home and community settings? c. To what extent are health sector employers shifting to casual and part time workers to b. How has deinstitutionalization affected meet flexible demands for labour? women who work as formal and informal caregivers? d. What is happening to the quality of care in the push for cost-effectiveness? c. What are the pros and cons of the shift to less institutional care? Who benefits? Who e. What is happening to holistic, individualized loses? treatment in a climate of standardized procedures? d. What work and health care costs are off- loaded to private households by the reduc- f. Are health care providers under pressure to tions in institutional care? minimize time spent with patients?

Page 66 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan g. Are the things which women want from the D. POLICY IS ABOUT MAKING health care system incorporated into health planners’ measures of desired outcomes? CHOICES h. To what extent are health sector employers Earlier this century, women on the Prairies or- contracting out services to private compa- ganized campaigns for public policies which nies? would address their needs for access to health care services. Women were involved in the po- i. How does the reorganization of health care litical and social movements which led to public work affect the health of women health care funding for hospitals, public medical insurance workers’ income, job security, stress, control for physician’s services, public programs of over work, social status, safety, and ability to support for other health care needs, and the rec- deliver quality care? ognition that health care is a public responsibility and a basic human right. j. How do private companies in the health sector compare with public services in terms of Today, women, as citizens, as care providers, quality of care, cost-effectiveness, conditions and as users of health services, are seeking ways of work, and access to services? to make the health system more responsive to their needs and concerns. Health policies must be analysed for differential impact among women, and between women and men. Women must be involved in the processes of policy evaluation and policy development. Women need the opportunity to participate democrati- cally in decision-making which will set the course for health care in the coming years.

There are choices to be made: choices regarding public funding for health care services; choices regarding public levels of responsibility for home care, elder care, patient care, midwifery, and prescription drugs; choices between public services and private providers; choices regarding the valuation and recognition of caregiving work as a social responsibility. Just as it was important for women earlier this century to communicate the conditions of their daily lives, their health concerns and their visions to citizen organizations, political parties, and policy-makers, so too are women’s voices needed today in the current debates over health care and health reform.

Page 67 References

Armstrong, Pat. “Closer to Home: More Work for Brownwell, Marni, Noralou Roos, and Charles Women” in Take Care: Warning Signals for Can- Burchill, Monitoring the Winnipeg Hospital Sys- ada’s Health System. Toronto: Garamond Press, tem 1990/91-1996/97. Winnipeg: Centre for 1994. Health Policy and Evaluation, 1999.

Armstrong, Pat and Hugh Armstrong. Wasting Away: Canadian College of Health Service Executives. The undermining of Canadian health care, To- Health Reform Update 1996-97, 1997. ronto: Oxford University Press, 1996. Canadian Healthcare Association. Canada’s Health Aronson, Jane. “Women’s Perspectives on Informal System under Challenge: Comprehensiveness and Care of the Elderly: Public Ideology and Personal Core Insured Benefits in the Canadian Health Experience of Giving and Receiving Care” in System. Ottawa: Canadian Healthcare Associa- Health and Canadian Society: Sociological Per- tion, 1996. spectives, (3rd edition), edited by David Coburn, Carl D’Arcy and George Torrance, Toronto: Uni- Canadian Home Care Association in collaboration versity of Toronto Press, 1998. with l’Association des CLSC et des CHSLD du Québec. Portrait of Canada: An Overview of Biggs, Lesley. “Building Binges and Budget Cuts: Public Home Care Programs (Draft), February Health Care in Saskatchewan, 1982-1990" in 1998. Devine Rule in Saskatchewan. Edited by Lesley Biggs and Mark Stobbe, Saskatoon: Fifth House, Canadian Institute for Health Information (CIHI), 1991. “Manitoba Health Expenditures,” www.cihi. ca/facts/manhe.html Black, Errol and Jim Silver, A Flawed Economic Ex- periment: the New Political Economy of Mani- Canadian Institute for Health Information. National toba, Winnipeg: Canadian Centre for Policy Al- Health Expenditure Trends, 1975-1998. Ottawa: ternatives, June 1999. Canadian Institute for Health Information, 1998.

Blakley, Bonnie and JoAnn Jaffe, Coping as a Rural Canadian Labour Congress, Women’s Work: A Re- Caregiver: The Impact of Health Care Reforms port. Ottawa: Canadian Labour Congress, 1997. on Rural Women Informal Caregivers, (Draft), 1999. Canadian Union of Public Employees, Cooking Up a Storm: Part II, 1998. Brown, Carol. Profile of Reductions in Health Care in Saskatchewan. Saskatchewan Public Health Canadian Union of Public Employees. Protecting Association, 1987. Public Health Care, CUPE Saskatchewan Policy Paper, March 1999.

Page 68 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Carrière, K.C. DeCoster, Sandra Peterson, Randy Health Canada, Provincial Health System Reform in Walld, Leonard MacWilliam, summary by RJ Canada - Manitoba Version 3, Health Canada: Currie, Surgical Waiting Times in Manitoba, 1997. Winnipeg: Manitoba Centre for Health Policy and Evaluation: 1998. Health Reform and Women: Opportunities for Change. Proceedings of the 1999 Provincial Fo- Chin-Yee, Fiona. Shifting the Goal Posts and Chang- rum, Winnipeg, March 1999. ing the Rules: The Privatization of the Canadian Health Care System, M.A. Thesis, Acadia Uni- Health Services Utilization and Research Commis- versity, 1997. sion (HSURC). Long-Term Care in Saskatche- wan: Final Report. Saskatoon: 1994. Cyrenne, Philippe. Analysing Shared Service Con- tracts: The Case of Food Services for Winnipeg Health Services Utilization and Research Commis- Hospitals, Canadian Centre for Policy Alterna- sion (HSURC). Measuring the Effectiveness of tives: June 1999. Home Care. HSURC Background Paper No. 1. Saskatoon: 1996. Doerksen, Glenda. “Providing Care” in Health Re- form and Women: Opportunities for Change, Health Services Utilization and Research Commis- 1999 Provincial Forum, Winnipeg: Women’s sion (HSURC). Hospital and Home Care Study. Health Clinic, March 1999. Summary Report No. 10. Saskatoon: 1998.

Dusel, Susan. “Government puts the brakes on Home Care and Policy: Bringing Gender into Focus. women’s movement,” Network of Saskatchewan Gender and Health Policy Discussion Series Pa- Women, Vol. 4, No. 7, 1987. per No. 1, Maritime Centre of Excellence for Women’s Health, March 1998. Fuller, Colleen. Caring for Profit, Vancouver: New Star Books, 1998. Horne, Tammy, Lissa Donner and Wilfreda E. Thurston, Invisible Women: Gender and Health Fuller, Colleen. Privatization in British Columbia Planning in Manitoba and Saskatchewan and (Draft Report), BC Centre of Excellence for Models for Progress, Winnipeg: Prairie Women’s Women’s Health: March 1999. Health Centre of Excellence, 1999.

Gardner, Ellen. “The Gathering Storm,” Briarpatch. Lees, Carol. Public Forums on Unpaid Work in Sas- November 1998, pp. 12-14. katchewan. Saskatoon: International Centre on Unpaid Work, 1997. Hall, Madelyn and Betty Havens. The Effect of Social Isolation and Loneliness on the Health of Older LeMoal, Larry. “Nursing: In sickness or in health?” Women, 1999. Spectrum, January 1998.

Harrison, Lesley Graff, Noralou P. Roos, and Marni Lett, Dan. “Food Fiasco costs millions,” Winnipeg Brownell, summary by R.J. Currie, “Discharging Free Press: December 3, 1999, pp. A1, A4. Patients Earlier From Hospital: Does it adversely affect quality of care?” Winnipeg: Manitoba Cen- Lett, Dan. “Health card quietly killed,” Winnipeg tre for Health Policy and Evaluation, 1995, www. Free Press: December 11, 1999, pp. A1, A4. umanitoba.ca/centres/mchpe/readmit.htm Living for Others: the Life Stories of Older Women Health Canada. “Health System Reform in Saskatch- in Saskatchewan. University of Regina Seniors ewan” in Health Reform Database, Overview by Education Centre, 1995. (Discussion Guide and Province, 1998-99. video)

Page 69 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

MacPherson, Jillian. “Midwifery threatened by lack Manitoba Nurses’ Union, Documenting Nursing of government support,” Saskatoon Star Phoenix, Workload: Workload and Staffing Report October 26, 1999. 1995/96, Winnipeg: Manitoba Nurses’ Union: 1996. Murray Mandryk, “New rules said to make care less personal,” Regina Leader Post, May 14, 1996. Manitoba Nurses’ Union, Health Care in Manitoba: A Report from the Front Lines. Winnipeg: Mani- Manitoba Advisory Committee to the Continuing toba Nurses’ Union, 1998. Care Program, Home Care Reform: Challenge and Opportunity, Manitoba Health: 1996. Maritime Centre of Excellence for Women’s Health, Home Care and Policy: Bringing Gender into Manitoba Centre for Health Policy and Evaluation, Focus, Discussion Series Paper No. 1, March “Bed Closures in Winnipeg: Problem or 1998. Progress? www.umanitoba.ca/centres/mchpe/bedclz3.htm Moon, Meaghan, Lorna Breitkreuz, Cathy Ellis, Cindy Hanson. Midwifery Care: What Women Manitoba Gazette, Vol.127. No. 42. Want, 1999.

Manitoba Health, Annual Reports 1992/93-1997/98. Nahmiash, Daphne and Myrna Reis. An Exploratory . Ottawa: Health Services Promotion Branch, Health Canada, 1992. Manitoba Health, Core Health Services in Manitoba, Manitoba Health, 1997. Nairne, Doug. “NDP stuck with Tory leftovers,” Winnipeg Free Press: December 3, 1999, p. A4. Manitoba Health News Release, “Five point plan announced to end hallway medicine,” November 22, National Council of Welfare, The 1995 Budget and 1999. Block Funding. Ottawa: National Council of Wel- fare, 1995. Manitoba Health News Release, “Manitoba Health to pay facility fees for all medically insured National Forum on Health. The Public and Private services,” December 30, 1998. Financing of Canada’s Health System. Ottawa: National Forum on Health, 1995. Manitoba Health, A Planning Framework to Promote, Preserve and Protect the Health of Personal Aspects of Poverty Group. Poverty, People, Manitobans. Winnipeg: Manitoba Queen’s Participation, Saskatoon, 1995. Printer, 1996. “Praznik stands behind oxygen pact,” Winnipeg Free Manitoba Health, Quality Health for Manitobans: Press, March 22, 1997. The Action Plan. Winnipeg: Manitoba Queen’s Printer, 1992. Russell, Frances. “Profit drives up health costs,” Winnipeg Free Press, December 8, 1999, p. A12. Manitoba NDP News Release, “Filmon’s layoffs Saskatchewan. Budget Address, Minister of Finance, coming back to haunt him,” February 9, 1998. 1996. Manitoba NDP News Release, “Privatization contin- Saskatchewan Commission on Directions in Health ues under new minister,” January 27, 1997. Care. Future Directions for Health Care in Sas- katchewan, Regina: Government of Saskatche- Manitoba NDP News Release, “Two-tier health sys- wan, 1990. tem evident in Westman,” March 17, 1998.

Page 70 MISSING LINKS: The Effects of Health Care Privatization on Women in Manitoba and Saskatchewan

Saskatchewan Health. Annual Reports 1991/92- Silver, Jim. The Cost of Privatization: Olsten Corpo- 1997/98. Regina. ration and the Crisis in American For-Profit Home Care. Winnipeg: Canadian Centre for Pol- Saskatchewan Health. A Guide to Core Services for icy Alternatives: 1997. Saskatchewan Health Districts. Regina, 1993. Silver, Jim “Privatization by Stealth: The Growth of Saskatchewan Health. A Population Health Promo- Private, For-Profit Health Care in Manitoba,” tion Framework for Saskatchewan Health Dis- Quarterly Review, Vol. 1, No. 1, Canadian Centre tricts, Regina, 1999. for Policy Alternatives, Winnipeg: 1999

Saskatchewan Health. Population Health Promotion Smillie, Adele. “Home Sick Home: A Study of Home Model: A Resource Binder, Regina, 1999 revi- Care in Saskatchewan,” Briarpatch, March 1998. sions. Smillie, Beth. “A Deal in the Making,” Briarpatch V. Saskatchewan Health. A Saskatchewan Vision for 23, n.3, April 1994. Health: A Framework for Change, Regina, 1992. Smillie, Elizabeth. “Dental Plan in Decay,” Network Saskatchewan Health. A Saskatchewan Vision for of Saskatchewan Women, Vol. 4, No. 10, 1987- Health: Challenges and Opportunities. 1992. 88.

Saskatchewan Health. Health Renewal is Working: Statistics Canada, Labour Force Historical Review, Progress Report, October 1996. 1999.

Saskatchewan Health. Drug Plan and Extended Statistics Canada. “Population 15 Years and Over in Benefits Branch. Annual Statistical Report 1996- Private Households by Census Family Status, 97. Presence of Children, Labour Force Activity and Sex, Showing Hours of Unpaid Care to Seniors, Saskatchewan Provincial Health Council. Population for Canada, Provinces and Territories,” 1996 Health Goals for Saskatchewan. Regina, October Census: www.statcan.ca/english/census96/mar17/ 1994. house/table11/t11p46a.htm

Saskatchewan Union of Nurses, Spectrum, Regina, Taylor, Georgina. “Mothers of Medicare” Women’s January 1998. History Month public lecture, Saskatoon, October 1998. Saskatchewan Union of Nurses, “Health reform offering constraints and opportunities,” Spectrum, Thompson, Loraine. Caregiving: Exploring the Op- January 1998. tions. University of Regina, Seniors Education Centre, 1998. Saskatchewan Union of Nurses, “How rationalization of health services is effecting nursing in Women’s Health Clinic, Womanly Times, Spring Saskatchewan,” Spectrum, January 1998. 1996.

Schmitz, Jan. “Women and Caregiving” WSRU Women and Health Reform Working Group, Health Newsletter, Saskatoon: Women’s Studies Reform - Making it Work for Women, Winnipeg: Research Unit, University of Saskatchewan, Women’s Health Clinic, 1997. Volume 11, Number 2, June 1998.

Shapiro, Evelyn. The Cost of Privatization: A Case Study of Home Care in Manitoba. Canadian Cen- tre for Policy Alternatives, Winnipeg: 1997.

Page 71