Geneviève Biron, head of Santé Québec, in her office in Montreal. Ms. Biron argues the agency is helping improve health care services and make the system more efficient, but critics say it’s another layer of bureaucracy.Andrej Ivanov/The Globe and Mail
In recent years, more than 70 different training modules for handwashing have circulated through Quebec hospitals and other health centres.
That’s not because there are dozens of ways to wash one’s hands. The problem is that different facilities were duplicating work.
This is one small example of a larger problem Geneviève Biron is trying to fix. As the CEO of Santé Québec, a Crown corporation created just over a year ago to operate Quebec’s health care network, she has been tasked with cutting costs, boosting efficiency and improving access.
“Things were done in silos before,” Ms. Biron said in a recent interview. “A unified health system is really a great way to be able to do things differently in the future.”
Governments across Canada are trying to solve intractable problems around health care delivery as they grapple with long wait times, staffing shortages and the expansion of private health care. In 2023, Premier François Legault bet on Santé Québec to fix a system that struggles to provide timely access to care. His is the latest in a series of Quebec governments that have looked to ever-increasing centralization as a key to health care reform.
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But critics say the Crown corporation is simply another layer of bureaucracy, and with a provincial election just months away, its future is uncertain. As governments in Alberta and Britain move in the opposite direction and dismantle their own centralized health care operators, Santé Québec is looking to prove the value of having one agency steering the ship.
Santé Québec took the reins of the province’s health network in December, 2024, absorbing 30 regional authorities into one organization and becoming the sole employer of 327,000 workers. The government instructed the new Crown corporation to eliminate a projected $1.5-billion deficit in the health care system for 2024-25.
Fifteen months later, Ms. Biron said the agency is already showing results. The number of people waiting more than a year for surgery is down by more than half, and wait lists for services such as child protection and mental health are also down. Meanwhile, the training tools for handwashing are being consolidated.
The Crown corporation ended its 2024-25 fiscal year with an operating deficit of $240-million, due in part to cuts worth $750-million and additional funding from the province.
“We can say it’s really under control, which is not the situation that was there prior to Santé Québec’s arrival,” Ms. Biron said.
But unions say cost-cutting has come at the expense of jobs and services, and that shorter wait times for surgery are because of an increased reliance on the private sector. To date, Santé Québec has “increased bureaucracy, increased the number of managers and reduced services on the ground,” said Réjean Leclerc, president of the Fédération de la santé et des services sociaux, a union representing 120,000 health care workers.
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This is not the first top-down overhaul of Quebec’s health care network. The 30 regional authorities supplanted by Santé Québec were formed in 2015 from the merger of 182 local health agencies. Those agencies were themselves created a decade earlier from the fusion of formerly independent hospitals, long-term care centres and rehab centres.
There was a “certain logic” to the centralization, said Régis Blais, a professor in the University of Montreal’s School of Public Health. “Some patients can fall between the cracks,” he said. “If we place these institutions under the same umbrella, services will be better coordinated.”
But Mr. Legault’s government didn’t need a new agency to unify health care delivery across the province, Prof. Blais said. He believes Santé Québec is an “unnecessary duplication” of the provincial health ministry.
“It’s a structure that is as cumbersome as the ministry and is becoming even more so,” he said.
Mr. Leclerc said Santé Québec isn’t nimble enough to respond to the needs of Quebec’s various regions. While Montreal deals with a large unhoused population, he said, people on the Gaspé Peninsula are more concerned about the distances they must travel to receive care.
“There are so many disparities that we cannot have a one-size-fits-all direction,” he said.
Alberta was the first Canadian province to fully integrate its health care system with the creation of Alberta Health Services in 2008.
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In 2021, an external review of Alberta’s early pandemic response found that having a single health authority created “structural advantages” in managing the first wave of COVID-19, as AHS had ready access to provincewide data.
But Premier Danielle Smith has blamed AHS, in part, for the province’s decision to impose COVID-era restrictions, and vowed to overhaul the health system when she became leader of the United Conservative Party in 2022. Her government has since dismantled AHS and created four organizations to oversee different facets of the health care system.
In the U.K., meanwhile, Prime Minister Keir Starmer announced last year he will abolish NHS England, which delivers health services in that country, with many of its functions to return to the health department. He said the move would cut bureaucracy and free up money for frontline services.
Santé Québec is facing similar existential threats, as Quebec’s governing party, the Coalition Avenir Québec, could be wiped out in the next election, scheduled for October. The Parti Québécois and Quebec Liberals have criticized the agency for a lack of concrete results.
Ms. Biron said Santé Québec should be given a chance. “I think we just need to be realistic. We’re just a year old.”
But Myles Leslie, an associate professor at the University of Calgary’s School of Public Policy, said all governments struggle with delivering health care, and there’s no consensus about whether a top-down or regional approach is best. Instead, the pendulum swings back and forth based on the political mood of the day.
“These problems are wicked,” he said. “They’re not solvable. They’re only manageable.”