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Abstract
Introduction Privatisation through the expansion of private payment and investor-owned corporate healthcare delivery in Canada raises potential conflicts with equity principles on which Medicare (Canadian public health insurance) is founded. Some cases of privatisation are widely recognised, while others are evolving and more hidden, and their extent differs across provinces and territories likely due in part to variability in policies governing private payment (out-of-pocket payments and private insurance) and delivery.
Methods and analysis This pan-Canadian knowledge mobilisation project will collect, classify, analyse and interpret data about investor-owned privatisation of healthcare financing and delivery systems in Canada. Learnings from the project will be used to develop, test and refine a new conceptual framework that will describe public-private interfaces operating within Canada’s healthcare system. In Phase I, we will conduct an environmental scan to: (1) document core policies that underpin public-private interfaces; and (2) describe new or emerging forms of investor-owned privatisation (‘cases’). We will analyse data from the scan and use inductive content analysis with a pragmatic approach. In Phase II, we will convene a virtual policy workshop with subject matter experts to refine the findings from the environmental scan and, using an adapted James Lind Alliance Delphi process, prioritise health system sectors and/or services in need of in-depth research on the impacts of private financing and investor-owned delivery.
Ethics and dissemination We have obtained approval from the research ethics boards at Simon Fraser University, University of British Columbia and University of Victoria through Research Ethics British Columbia (H23-00612). Participants will provide written informed consent. In addition to traditional academic publications, study results will be summarised in a policy report and a series of targeted policy briefs distributed to workshop participants and decision/policymaking organisations across Canada. The prioritised list of cases will form the basis for future research projects that will investigate the impacts of investor-owned privatisation.
- Health policy
- Health economics
- Health Equity
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Strengths and limitations of this study
This multimethod knowledge mobilisation project aims to identify new and emerging cases of privatisation across Canada’s healthcare system, laying the foundation for future research on effects.
Our team includes a breadth of expertise and perspectives from policy researchers, clinicians, representatives of for-profit and non-profit organisations and patients with lived experience; these diverse perspectives will inform our data collection, analysis and study outputs.
We will validate and refine the results of our document scan and analysis through interviews with experts and during our policy workshop.
In addition to traditional academic publications, we will produce summative advisory policy briefs based on key learnings, targeted to specific interested parties (such as provincial/territorial ministries of health).
Emerging cases of privatisation and corporatisation may be difficult to identify due to the lack of public disclosure and data on the ownership of healthcare infrastructure, such as primary care clinics, and many not be readily available in public sources.
Introduction
Publicly funded healthcare in Canada is a shared responsibility between the federal, provincial and territorial governments. Provincial and territorial governments are expected to manage, organise and deliver healthcare in ways that are consistent with the five principles outlined in the Canada Health Act—public administration, comprehensiveness, universality, accessibility and portability—in exchange for receiving federal transfer payments.1 This system is founded on the principle of universal publicly-funded coverage for medically necessary care provided in hospitals and/or by physicians based on need and not ability to pay.2 What is considered ‘medically necessary’ is determined by each province and territory largely through negotiation with the medical associations operating in that jurisdiction. Insured services covered under the Canada Health Act are intended to be 100% publicly-funded when provided to enrolled beneficiaries by enrolled physicians. Provinces use varied health insurance legislation in order to enforce compliance with the Canada Health Act, relying on some combination of constraints on (1) direct billing (charging patients directly for publicly insured services); (2) extra billing (charging patients an amount on top of coverage with the public plan); and (3) the ability to obtain private insurance for services covered by the public sector.3
There are growing concerns that healthcare systems in Canada may be shifting to include more private financing and more for-profit, investor-owned practices and facilities.4 5 This is a move away from the historical ownership model of hospitals and other facilities being either private not-for-profit or public. These financing and ownership changes sometimes occur quietly, rather than through explicit policy decisions, and are often the result of private actors seizing opportunities to profit.6 7 In other instances, they are introduced under the guise of improving access to care for those who can pay to purportedly take pressure off the public system.8 How these shifts unfold is not well documented and their consequences are not well understood. Private-pay and investor-owned for-profit healthcare delivery impact equitable access to healthcare for all,9–15 may increase spending on low-value services10 14–19 and undermine the underlying values of the Canadian healthcare system.11 12 15 18–21
Private financing in Canadian healthcare
Healthcare financing refers to the ways in which financial resources are raised to ensure that the healthcare system can cover the health needs of the population.22 It includes how revenues are raised (tax revenue, insurance schemes, out-of-pocket payments) and pooled, and how services are purchased (allocation of resources to specific sectors, services and providers).23
The private-public split in Canadian healthcare financing has historically hovered at around 70% public pay and 30% private pay (including individual out-of-pocket payments and services covered by private insurance).24 Additionally, the split varies dramatically across subsectors, with a much higher reliance on private financing for services not directly covered under the Canada Health Act (which only includes medically necessary services delivered in hospitals or by physicians).24 For example, only 38% of expenditures on prescription drugs are financed through public programmes.25 Dental care is also predominantly financed privately, with provinces and territories providing limited and variable public coverage typically for low-income residents and some seniors.26
There are concerns that private financing as a percentage of overall spending may be increasing, though shifting costs to out-of-pocket payments and investments in healthcare made by corporate entities are difficult to track.5 For example, the ratio of public to private payment for long-term care has fallen dramatically in British Columbia since the 1990s,27 28 and community-based and hospital-based physiotherapy services were long-ago delisted from public insurance in some provinces.29–31 After the 2005 Supreme Court of Canada’s Chaoulli v Quebec decision, complex corporate entities emerged that were designed to bypass regulations against extra billing,32 with the result that some patients in Quebec are often billed directly out-of-pocket for primary care services.33 Such shifts in financing have substantial implications for equitable access, with evidence that even small out-of-pocket charges can deter people from seeking healthcare.9–12 20
Shifts toward private investor-owned delivery and the relationships between financing and delivery
In addition to ‘privatisation’ through changes to financing, there have also been shifts in the delivery system, which is defined broadly as the way in which healthcare services are owned, organised, managed and provided to meet the health needs of a target population.34 Private delivery is longstanding in Canada, as most physician practices are private small business sole proprietorships delivering publicly funded services. However, investor-owned service delivery is increasing.4 5 While some of these companies charge patients privately, many operate predominately through public financing.35
One example of a model that includes both public and private financing and delivery is virtual ‘walk-in’ clinics, the use of which have substantially increased since the beginning of the COVID-19 pandemic.36 These clinics come with threats to continuity of care,37 duplication or overuse of services38 and commercialisation of personal health data.36 Many of these clinics exclusively bill provincial public insurance plans for insured benefits provided to enrolled beneficiaries, while others charge patients directly for supplemental services. Some services do both, billing public insurance for some services and charging patients privately for text messaging or other services not included in public plans.37 Employers are increasingly offering virtual healthcare and physician services to employees through for-profit virtual ‘enterprise’ platforms that are paid through what is ostensibly private supplemental insurance, but which looks increasingly like duplicative insurance which is banned in six Canadian provinces.39
There is a shortage of accessible primary care currently across Canada.40 41 This shortage has meant that more Canadians are struggling to access timely care, leaving a place for investor-owned corporations to take advantage of unmet demand.42 Direct out-of-pocket private payment by patients for medically necessary services is increasingly common,42 challenging the substance and spirit of the Canada Health Act.43 44 Despite this, we lack robust data on the actual prevalence of private pay services. While ‘executive’ or ‘boutique’ clinics have existed for some time, large corporations such as Walmart, Telus and others have recently purchased networks of clinics, charging patients for non-insured bundled services and/or annual subscription fees while also billing provincial insurance plans for publicly-insured services.42 45 46
These acquisitions represent increasing corporatisation and investor-ownership of Canada’s historically private not-for-profit or publicly-owned health services delivery infrastructure. In addition to raising concerns about access and equity, corporatisation may amplify the effects of information asymmetry between clinicians and patients, increasing the potential for ‘upselling’ and other ‘consumer’ orientations that promote greater spending on services that have little real clinical value. Research from the USA suggests that these acquisitions result in increased patient volume, with an overuse of profitable services or low value care, increasing healthcare spending without clear benefits.16–19
Starting conceptual framework
‘Privatisation’ may involve shifts in financing (eg, user fees, delisting insured services, increasing private duplicative insurance) or in delivery (eg, public-private partnerships, corporate or investor ownership of delivery systems or subcontracting).47–49 As such, the long-standing debate about ‘privatisation’ has been framed around a 2×2 framework of ‘public vs private financing’ and ‘public vs private delivery’. This framework, however, misses the nuanced ways that public and private elements of the system interface and interact. Figure 150 improves the 2×2 framework, but still fails to capture other important dimensions, such as distinguishing between services covered and not covered by the Canada Health Act, corporatisation, investor-ownership, out-of-pocket payments (eg, user fees) and private insurance. This illustrates the need for a more nuanced conceptual framework.
Nine possible public–private interfaces in Canada.
Objectives
Our project responds to the urgent need to document and categorise new or expanding forms of private financing and for-profit investor-owned delivery and to provide tailored information to interested parties about its potential effects. For brevity and readability, we refer to the spectrum of changes that are affecting sources of financing and types of delivery as ‘privatisation’. Our objective is to lay the groundwork for future studies that investigate the effect of the expansion of private-pay and for-profit investor-owned healthcare delivery in Canada in specific areas of high importance to policymakers and the public. Our specific objectives are to:
Describe and document new and emerging examples of the forms and extent of private financing (out-of-pocket payments and/or private insurance) and delivery (for-profit, investor-owned) in Canada’s 13 provincial and territorial healthcare systems, including sectors that appear to be experiencing the greatest shifts.
Expand and update the conceptual framework for categorising and analysing the privatisation of financing and delivery.
Prioritise healthcare sectors and/or services for future in-depth research to provide tailored information to interested parties about potential effects of shifts toward greater privatisation of healthcare.
Methods and analysis
Overall study design
This is a 2-year knowledge mobilisation project to collect, classify, analyse and interpret data triangulated from multiple sources, and synthesise data about privatisation of healthcare systems in Canada. Starting in summer 2023, our multidisciplinary team will conduct an environmental scan to refine the starting conceptual framework (Phase I); in summer 2024, we will convene a virtual policy-workshop that includes a Delphi-based prioritisation exercise (Phase II); and in late summer/early fall 2024, we will integrate feedback, finalise and disseminate the framework. We will include the final framework in a policy report, to be distributed by early 2025, that summarises the ways in which privatisation is occurring and its possible implications with respect to health equity. The report will also include a prioritised list of subsectors/programmes that will be the target of future in-depth case studies. In this context, a ‘case’ is the health sector, healthcare intervention, programme or domain identified during the document analysis and interviews where a new, expanding or emerging form of privatisation is occurring. We are currently finalising our data collection processes and tools, in preparation for beginning the environmental scan (Phase I).
Phase I: Environmental scan
Document analysis
We will conduct three scans to identify: (1) other existing frameworks or typologies that describe public/private financing and delivery of healthcare (Scan 1); (2) provincial/territorial and national legislative and policy documents, and government briefings (to document existing policies that underpin public-private interfaces, such as rules allowing physicians to opt-out of public provincial insurance programmes), highlighting differences across provinces/territories (Scan 2); and (3) articles, news reports and other communications that describe a healthcare intervention, programme, technology or domain in which there is at least some degree of a ‘new form’ or expansion of privatisation (Scan 3).
Search strategy, data sources and inclusion criteria
Initial details of our draft search strategies, data sources and inclusion and exclusion criteria for the three scans are included as supplemental material (online supplemental appendix 1) and will be refined through discussions with our research team, knowledge user partners and an experienced information specialist with expertise in systematic searches. Searches for policy documents and examples of privatisation will be limited to Canada; however, we will include international literature to identify other typologies or frameworks.
Supplemental material
All three scans will use multiple search strategies, including: (a) database searches of MEDLINE (PubMed, OVID), CINAHL Complete, Canada Research Index, Canada Commons, Policy Commons, Business Source Complete, Canadian News Streams, Google Scholar; (b) targeted searches using Google Advanced Search of website domains, including those of provincial, territorial and federal health administrative agencies and authorities, health professional organisations, ministries of health, legislatures, standing committees on health services and planning and health and policy advocacy organisations; (c) snowball searches from our initial database and website search results; and (d) professional contacts and networks for documents that may not be readily publicly available.
The database and targeted website searches will use a combination of Medical Subject Headings and relevant keywords and phrases, including but not limited to: ‘health care’, ‘healthcare system’, ‘health system’, ‘private’, ‘privatisation’, ‘healthcare financing’, ‘healthcare reform’, ‘health policy’, ‘healthcare policy’, ‘healthcare insurance’, ‘universal health care’, ‘universal health coverage’, ‘profit’, ‘investor’, ‘private pay’, ‘corporation’, ‘commercialise’, ‘entrepreneur*’, ‘revenue’, ‘marketisation’, ‘acquisition’. Scan 1 will also include terms such as ‘framework’, ‘conceptual model’ or ‘typology’ while Scans 2 and 3 will include jurisdictional keywords such as ‘Canada’ and Canadian provinces and territories.
Scan 1 will include documents that develop or include a conceptual framework or typology for evaluating public–private interfaces in health systems that were published (in English or French) between 2000 and 2022. Scan 2 will include policies that directly address public-private delivery or financing of healthcare in Canada that were published (in English or French) between 1984—the passage of the Canada Health Act—and 2022. Scan 3 will include policies that directly address public-private delivery or financing of healthcare in Canada, as well as documents that highlight an example of privatisation of financing or delivery that is new or growing in Canada, published (in English or French) between 2010 and 2022. The start date was selected as 2010 as we are interested in recent examples of forms of privatisation that are new or emerging, rather than ones that have long been a part of the system.
Data abstraction and analysis
Two team members will screen each document for eligibility and extract data according to structured templates designed for each of the three scans. For Scan 1, we will abstract: (1) a description of the public-private interface explored; (2) the health system or sector implicated; and (3) a summary of the framework or model presented. For Scan 2, we will abstract: (1) the organisation issuing the policy and the jurisdiction to which the policy applies; (2) the public-private interface targeted by the policy; (3) the health system(s) or sector(s) affected by the policy; (4) a summary of the policy and the type of policy instrument (eg, do nothing, exhortation, expenditure, regulation, public ownership51); and (5) any evidence of intersectional and/or gender-based analyses included in the policy. We will compare the starting framework (figure 1) to any other relevant frameworks, and in relation to the underlying provincial, territorial and national legislation and policies we identify during the environmental scan.
For Scan 3, we will abstract: (1) a description of the healthcare intervention, programme, technology or domain; (2) the dimension(s) of expanding and emerging privatisation (eg, loss of coverage under public health insurance programmes, user or membership fees, corporatisation, investor ownership, public-private partnerships, subcontracting); (3) province/territory or region, and specific health sector; and (4) any noted impacts, particularly those pertaining to equity. Then, using pragmatic content analysis,52 53 at least two members of the research team will independently code abstracted data relevant to examples of new, expanding or emerging privatisation. Any coding disputes will be resolved through discussion.
We will use the synthesised data to identify gaps in, and strengths and limitations of, our starting framework; to identify additional dimensions to incorporate into an expanded framework; and to describe the relationship between dimensions. The research team will also review the list of potential cases and will align them within our revised framework. The revised framework, long-list of cases and potential impacts will be included in a draft policy report.
Key-informant interviews
We will use semi-structured qualitative interviews with 10–15 policy and decision-makers, and 5–10 health policy and legal experts to: (1) identify any documents, conceptual frameworks, studies, or new, expanding or emerging areas of privatisation that have been missed in our environmental scan; (2) confirm our interpretation of findings; and (3) help to validate potential cases that have been previously tentatively identified through the document analysis that will be included in the long-list for our Delphi process, or areas we may wish to investigate in more depth. Our intention to conduct 20–25 interviews is based on previous work we have conducted in this area, and our intention to reach thematic saturation and investigate differences by subgroups of interest. This sample is a starting point and we will conduct additional interviews as needed.54 55 We will gather relevant demographic (eg, gender, years of experience) and professional (eg, organisation, role) characteristics to describe study participants. Interviews will take 30–45 min and will be conducted by trained qualitative research staff on Zoom or by telephone. They will be recorded and professionally transcribed for analysis.
Recruitment
Eligible informants are health system policy or decision-makers including representatives from provincial/territorial ministries of health and regional health authorities, relevant pan-Canadian organisations (eg, Canada Health Act Division of Health Canada, Canadian Medical Protective Association, College of Family Physicians of Canada, Royal College of Physicians and Surgeons of Canada, Canadian Association for Health Services and Policy Research, McMaster Health Forum), and private, corporate healthcare providers (eg, Telus, Maple, Well Health). We will identify content experts through the environmental scan and will include academics and practitioners who lead relevant research or practice programmes with a focus on Canadian health policy, health law or other applicable areas. Across all interviews, we will aim to represent a diversity of roles, provinces/territories, organisations and relevant areas of expertise. Our study team includes, and has existing relationships with, several policy makers and content experts and we will work together to draft an initial list of potentially relevant key informants.
Analysis
We will analyse interview transcripts using inductive content analysis52 53 facilitated by NVivo V.14 software. Our analysis will focus on manifest content (rather than latent content),53 56 and will proceed through the stages of decontextualisation, recontextualisation, categorisation and compilation.53 To develop a coding template, at least two team members will perform initial analysis. To enhance the rigour of our interviews and analyses,57 we will document our interviewing, transcription and coding protocols; use trained qualitative analysts and interviewers; and keep detailed records of field notes, group meetings, coding disagreements and resolutions.56 58 We will encourage and document self-reflection among all members of the research team.59
Phase II: Virtual policy workshop and Delphi exercise
We will convene a virtual policy workshop to (1) seek subject area expert feedback on the initial policy report, with specific focus on the refined framework; and (2) prioritise the long-list of potential case studies using an adapted James Lind Alliance (JLA) Priority Setting Partnership process. JLA uses a Delphi process for consensus development, involving multiple rounds of priority identification and prioritisation through structured questionnaires and discussion.60 It is designed to produce a list of the top 10 research priorities in a particular area, reflecting the joint perspectives of diverse subject area experts and interest groups.
Recruitment
Using direct email outreach, we will invite participants from the interviews in Phase I, as well as additional relevant subject area experts and interest groups identified through snowball sampling during our interview and document analysis. We will aim for 20–25 participants for the virtual workshop. Potential key informants include representatives from provincial and regional health policy organisations, pan-Canadian policy or advocacy organisations (eg, Canadian Doctors for Medicare, Conference Board of Canada), clinicians, individuals with lived experience (through Patient Advisors Network, Strategy for Patient Oriented Research Council, Health Data Research Network’s Public Advisory Council and others), and members of the business community with expertise in health system innovation. We will use a stratified, purposeful recruitment strategy to ensure we include individuals with diverse perspectives, demographic characteristics and lived experiences.
Event
Prior to the workshop, the study team will create a draft policy report that integrates key findings from the document scans and interviews. The report will include a revised framework, a summary of the ways in which privatisation is occurring across health systems in Canada and a long-list of potential subsectors/programmes (cases) that will be the basis of future in-depth case studies.
In the weeks leading up to the workshop, participants will be asked to participate in a virtual interim prioritisation exercise. They will be provided with a copy of the draft report and asked to select their top 10 cases in a rank order, taking note of the rationale for their decisions and focusing specifically on the potential for impact on equity, quality of care and health system costs. The top 20 ranked cases will be brought forward for final prioritisation and discussion at the workshop.
Final prioritisation at the workshop will use a nominal group technique.61 In small groups, participants will discuss their views on the potential impacts of each case and on a shared ranking for the 20 cases. They will again be asked to consider which cases have the greatest potential for impact on equity, healthcare quality, healthcare access and health system costs. Each group’s rankings will be entered into a spreadsheet to calculate a single overall ranking, which will be discussed and re-ranked in small groups. These new scores will then be aggregated, and the final ranking discussed in a large group session to settle on a final top 10.
In addition to prioritising case studies, a portion of the workshop time will be devoted to collecting feedback on the conceptual framework and policy report. Participants will be asked whether the framework is clear and captures all potential public-private interfaces. They will be asked whether any new, expanding or emerging cases of privatisation are missing from the report, and whether the ones we have included are accurately presented with potential impacts and uncertainties sufficiently described.
Patient and public involvement
Our Canadian multidisciplinary team includes patient and community partners, who are coauthors on this protocol and have been integrally involved in developing the methods for this study. They will continue to provide guidance as the study proceeds. Additionally, knowledge user partners, Canadian Doctors for Medicare (principal knowledge user), Conference Board of Canada and Doctors Nova Scotia, will assist the study team with identifying relevant documents for our scan, identifying and recruiting interviewees and policy workshop participants, interpreting results, participating in the policy workshop and Delphi exercise and sharing our policy report and briefs with their broad networks.
Ethics and dissemination
Ethics approval, informed consent and confidentiality
We have obtained approval from the behavioural research ethics boards at Simon Fraser University, University of British Columbia and University of Victoria through Research Ethics British Columbia (H23-00612).
For the qualitative interviews and virtual policy workshop, the study team will contact interested participants to provide them with study information and obtain their written informed consent. We will inform participants that they can choose not to answer any of the study questions and can withdraw their consent at any time.
Knowledge translation
We will use the feedback we receive at the policy workshop to revise our policy report, framework and list of priority case studies. The final report will highlight the top three priority cases. We will also draft summative advisory policy briefs based on key learnings within the report, targeted to specific affected groups (such as provincial/territorial ministries of health).
We will develop a Knowledge Translation (KT) Plan to enable sharing of final documents with workshop participants and relevant decision/policymaker organisations across Canada. This will include writing articles for publication in peer-reviewed open access journals and op-eds, conducting media interviews, providing debriefings to relevant organisations by Zoom, participating in online discussions (eg, healthydebate.ca) and using social media to disseminate findings. We will also share findings through regional, national and international conferences (virtually or in-person). Ultimately, we will generate evidence that will advance the understanding of the shifts in financing and delivery and inform policy action, with the aim of contributing to ongoing conversations about health care system changes in Canada and the principles and values they reflect.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @LindsayKHedden, @faussenurse, @RuthLavergne, @DrRitaMc, @kimchspr, @MGVanstone
Contributors The first author is the lead and corresponding author. Contributions to the manuscript are described using the CRediT taxonomy (Brand et al (2015), Learned Publishing 28(2)). Writing—Original Draft: LH. Writing—Review and Editing: LH, SSpe, SA, DC, FG, AG, MRL, CL, JL, MMc, MMa, RKM, KM, KSP, M-EP, DR, SSpi and MV. Conceptualisation: LH and KM. Methodology: LH and KM. Supervision: LH. Project Administration: LH and SSpe. Funding Acquisition: LH, SA, DC, FG, AG, MRL, CL, JL, MMc, MMa, RKM, KM, KSP, M-EP, DR, SSpi and MV. All authors have read and approved the final manuscript.
Funding This study is funded by a grant from the Canadian Institutes of Health Research (492157). Lindsay Hedden is supported by a Michael Smith Health Research BC Scholar Award (SCH-2021-1510). M Ruth Lavergne is supported by a Canada Research Chair (Tier 2) in Primary Care. Meredith Vanstone is supported a Canada Research Chair (Tier 2) in Ethical Complexity in Primary Care.
Competing interests Between 2019 and 2022, JL received payments for writing briefs on the role of promotion in generating prescriptions for two legal firms. He is a member of the Foundation Board of Health Action International and the Board of Canadian Doctors for Medicare. He receives royalties from University of Toronto Press and James Lorimer & Co. Ltd. for books he has written. All other authors declare no competing interests.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; peer reviewed for ethical and funding approval prior to submission.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.