Government & Medicine

Rage against � or for? � the machine

Politicians make baby steps towards P3s.
Is Canada ready to bet the healthcare farm?

By Susan Usher

Anathema to medicare diehards, public-private partnerships (P3s) are nevertheless on everyone's lips these days. Communities across Canada are struggling to upgrade their healthcare facilities and P3s often crop up as a healthcare messiah. Some love the idea, others hate it, but despite the ideological clashes surrounding them few are clear on how they'll actually work. Provinces thinking about introducing the projects are at high risk of catching P3 fever � puzzled, persecuted and paralyzed � unless they can clarify the fuzzy areas.

BC is moving along in its P3 plans with a provincial agency, Partnerships BC, driving two major capital projects now at the planning stage including a new Academic Ambulatory Care Centre with teaching and clinical services provided by Vancouver Coastal Health Authority and the UBC Faculty of Medicine.

Meanwhile, Ontario is planning the Brampton Health Centre and the Royal Ottawa Hospital as P3s, with private corporations financing and running the facilities and leasing them to the hospital. The Ontario Health Coalition is up in arms about government's attempts to hide the fact that these are private ventures. They're also fuming over the foggy details surrounding what services are in the agreement, how long the leases would be and what costs and profits are involved.

MULRONEY'S TWO CENTS
In Quebec, Brian Mulroney and ex-Premier Daniel Johnson are co-Presidents of the commission studying plans for the two university superhospitals to be built in Montreal. They're seriously considering P3 options. In their April report to Quebec Health Minister Philippe Couillard, Mr Mulroney and Mr Johnson expressed serious concern over the risk of cost overruns and suggested that the private sector was better equipped to run these risks in the planning and construction of new facilities.

Hugh Segal, President of the Institute for Research in Public Policy, is particularly well placed to assess these provincial issues. He sees some definite advantages to getting private corporations on board in the early stages of upgrading health facilities. "It's not actually possible for governments to retain in their permanent staff or within their crown corporations all the expertise necessary to be right on top of the best ways to do these particular undertakings," says Mr Segal. "Sometimes by making partnerships with the private sector, they gain a much more contemporary skill set."

Mr Mulroney and Mr Johnson are confident that such partnerships wouldn't amount to privatization of health services. Only non-clinical activities like planning, building and upkeep would be included. Mr Segal agrees. "There's no reason that the agreements under which these organizations operate need be any less reflective of public policy goals or instruments than is the case with a fully operational 100% pure public institution," he says.

Of concern to the Ontario Health Coalition is the scant info on the finances of the P3 deal for the proposed Brampton facility. "The secrecy surrounding the use of our money is scandalous," commented Dora Jeffries, co-chair of the Brampton Health Coalition, at the time. The Coalition hopes to get access to the schedule of payments, borrowing rates and profits and the list of services to be privatized. They also want to be privy to the Value for Money report prepared for government, and lease details.

NOTHING TO WORRY ABOUT?
Mr Segal insists that the quality of universal access can be maintained when private partners are involved as long as the terms are clearly defined. "The terms of reference under which bids are sought should be very public with absolutely complete transparency," he says. "There will, however, be areas of commercial competitiveness where normative protections should be in place."

Mr Mulroney and Mr Johnson haven't yet bet the farm on the private sector, but feel that considering P3s alongside other options is "essential," as they may be able to greatly trim down the costs of upgrading some of our aging healthcare facilities.

Acceptance of P3s hangs largely on that uncertainty. Yes, governments and health regions would welcome a quick infusion of private cash to fund projects the public purse can't afford, but how long will public money continue to pay for the facilities, and what will the price tag be? Comparing the costs for each option is difficult without accurate figures.

"The choice of model," concludes Mr Segal, "has to be on a basis that is less expensive � in the short, medium and long term � to the tax payer, and more efficient in terms of producing the facility quickly than would be a 100% wholly public sector operation."