In contemplating more private delivery, the for-profit element requires careful scrutiny.
No, said Dr. Nuala Kenny, founding member of Canadian Doctors for Medicare and founding Chair of the Department of Bioethics in Dalhousie’s Faculty of Medicine.
In contemplating more private delivery, the for-profit element requires careful scrutiny. Our system has used private delivery from the beginning, only it has been private not-for-profit delivery.
Many European countries require that the same fee be paid for a service whether it is provided by a public or private provider. Not all needed health care services are amenable to the requirements of making a profit and there is a danger that increased reliance on for-profit private delivery would promote the development of health services that are profitable at the expense of those that are not and leave us without an appropriate full spectrum health system.
We have, in Canada, seen public health care institutions contract with private for-profit delivery operations in hopes of shortening wait lists and injecting extra money into the system. That might make sense to clean things up and set a level playing field, but the risk augments when public money is called in to buttress private for-profit health providers. Recent reports published from Australia state that some $3 billion in public funds are being spent every year now to keep private for-profit health care providers going. We need to guard against mechanisms that permit that kind of bail-out.
New Brunswick Ambulance (see the Case Study) is a fantastic example of public money protecting public health care and developing a partnership with a private corporation to create a system that has run very effectively. We should not encourage private delivery out of enthusiasm for the market in and of itself, but rather ask in what way the preservation of our public equity health system could be expressed in market activity.
Positive accounting is one area where the private sector could contribute significantly to meeting the goals of an equitable public health system. Our general accountability at all levels is very poor and has to be improved. We should learn from for-profit organizations how to demand accountability from the corporation to the shareholders and start providing that to Canadian citizens, as shareholders in the health system.
Market mechanisms are well suited to increasing choice and treating patients as consumers. There are some potential benefits to that approach but it is often ill-suited to the sickness/illness encounter. The market is also about competition, which can bring positive changes but also has some negative sides, especially when applied to health care. Competition requires advertising, which involves the creation of need and promotes specialization.
The kind of private for-profit technological fixes we have been looking to in Canada will not help us improve health promotion, disease prevention or chronic illness management: i.e. the full health care continuum.
Summation If we separate funding and delivery in our discussion of the benefits of more private involvement, we have lots to talk about. What we need at this stage in the discussion are clear examples: if we are going to use European examples they cannot be generic and we need to ask what kind of protection they offer the public system, what limitations they impose on practice, and what kind of accountability they demand. ■
Nuala Patricia Kenny, MD, FRCP (C), was Head of the Department of Pediatrics at Dalhousie, founding Chair of the Department of Bioethics in Dalhousie’s Faculty of Medicine and was seconded as Deputy Minister of Health for the Province of Nova Scotia in 1999. Dr. Kenny was Chair of the Values Committee of the Prime Minister’s 1997 National Forum on Health. Her first book, What Good is Health Care? Reflections on the Canadian Experience, was published by CHA Press in 2002. Her second edited text, Lost Virtue: Professional Character Development in Medical Education, was published by Elsevier Press in October, 2006.