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Private Sector Delivery: Scope and Extent in Canada's Health Care System
Investigator Name: Ian McKillop, Ph.D.
Project Completion Date: February 2005
Research Category: Research
Institution: University of Waterloo
Project Number: 6795-15-2002/4570001
Summary
Health services in Canada are delivered by a comprehensive range of public and private sector providers. Although a wealth of information describing the consumption of health services by Canadians is available through sources such as Statistics Canada and the Canadian Institute for Health Information, together with detailed information describing health services provided by public agencies, access to consolidated information describing the scope and extent of private sector involvement in delivering health services to Canadians is much more limited.
Commissioned under the Health Policy Research Program of Health Canada, the study seeks to address this shortcoming by gathering aggregate data about a range of privately delivered health services from key informants coast to coast, and combining this information (where possible) with information available from secondary sources.
The study will be of interest to policy makers, researchers, and providers themselves. It represents one of the first efforts to develop a comprehensive inventory of the role played by the private sector in the delivery of health care services in Canada - a sector estimated to represent at least $36 billion in health spending in 20031.
The health services examined include:
- Chiropractic services;
- Continuing care - both facility based (residential health care facilities) and home care;
- Dental care (including dental surgeon and dental hygiene services);
- Diagnostic imaging and laboratory services (including radiation technologies);
- Hospital based care (including purchased and referred-out-services);
- Nursing care;
- Optometry services;
- Physician care;
- Rehabilitation services not hospital based (including massage therapy, occupational therapy, physiotherapy, respiratory therapy); and
- Other health services (including midwifery, naturopathic, podiatry).
Executing the study was made challenging by the fact that background research revealed there is not a single, universally accepted definition of what constitutes private sector involvement in the delivery of health services.
In the absence of a universally accepted definition, the study makes an explicit effort to embrace a variety of viewpoints or perspectives. This allows users of the study - be they health economists, planners, policy analysts, researchers, or providers themselves - to apply the lens most appropriate for their needs when considering the data that has been collected.
Three perspectives are used to organize the findings. The first considers private sector delivery to exist when providers exhibit structural characteristics commonly found in the private sector - such as being organized as a "for profit" entity.
A second viewpoint considers private sector delivery activities to exist when providers have a high level of control over the resources needed to provide care - such as having the ability to make decisions about resource allocations, administrative structures, opening hours, etc.
A final perspective considers private sector delivery to exist when payment for the services rendered comes from non-public funds.
As the report demonstrates, all three of these perspectives represent valid and accepted viewpoints when assessing whether private sector delivery activities are present. The decision about which perspective is the most appropriate to use must be determined by the nature of the question being asked.
It is hoped that the utility of the study is enhanced by this approach, thus providing the greatest benefit to readers interested in understanding the scope and extent of private sector involvement in the delivery of health services in Canada.
The report contains only summarized results. An electronic Findings Database with an accompanying data browser application is available to interested readers. The data browser application provides more freedom to explore the data collected than is possible through the presentation of static exhibits.
The data browser application can be obtained directly for the ideas FOR HEALTH research cluster
at the 
University of Waterloo (ideas.uwaterloo.ca).
What We Learned
The study unfortunately confirms one of the reasons originally used to motivate the project - there is a dearth of information available that accurately describes the scope and extent of private sector delivery activities in Canada. The project charter made the assumption that these data exist, and that the underlying challenge was simply to identify these data, and collect the data into a consolidated format.
Sadly, the study reveals that the problem is not one of simply collecting the data needed to accurately describe the private sector's involvement in Canada's health care system. It appears that data to make this assessment is, in many cases, not routinely collected by provider organizations themselves, or by other parties who might otherwise be expected to have insights into this dimension of Canada's health care system.
The encouraging news is that rather than express concern about the creation of a consolidated database describing private sector involvement in Canada's health care system, many private sector providers and provider organizations endorsed the effort being made by researchers and Health Canada to develop such an inventory.
Private sectors providers know that they play a significant role in delivering health services to Canadians. They also shared that they sometimes feel their role is misunderstood or misrepresented.
And herein lies the dilemma. Private sector providers appear extremely interested in ensuring that the scope and extent of the services they provide be properly recognized in the datasets used by the researchers, policy analysts and decision makers involved in guiding the direction of Canada's health care system. At the same time, private sector providers are cautious about how these data could be used to draw inappropriate conclusions about the role they play in Canada's health care system, or to potentially compromise their competitive position in the marketplace through the disclosure of sensitive information.
Key Findings
Information reflecting the activities of over 135,000 health care providers was collected for this study.
Irrespective of the perspective taken (structure, funding or control), the following health services exhibit attributes indicating significant private sector delivery activity:
- Chiropractic services
- Dental care
- Optometry
- Rehabilitation - massage therapy
- Midwifery
- Naturopathy
- Podiatry
In contrast, nursing and respiratory therapy services providers exhibit attributes suggesting a fairly low involvement in private sector delivery activities. The unit of analysis may be affecting this observation.
Overview of Findings
| Service J = number of jurisdictions reporting p / e = # of providers / entities (centers, facilities, operators) reporting |
When viewed from a structural perspective | When viewed from a control perspective | When viewed from a funding perspective |
|---|---|---|---|
Chiropractic |
97% |
96% |
97% |
Continuing Care - Home Care |
100% |
100% |
99% |
Continuing Care - |
32% |
100% |
36% |
Dental Care - Dental Surgeons |
93% |
85% |
94% |
Dental Care - Dental Hygienists |
11% |
11% |
97% |
Diagnostic Imaging |
< > |
< > |
< > |
Laboratory Technology |
29% |
1% |
29% |
Radiation Technology |
30% |
< > |
30% |
Hospital based Care |
< > |
< > |
< > |
Nursing Care |
1% |
5% |
1% |
Optometry |
93% |
66% |
75% |
Physician Care |
< > |
< > |
< > |
Rehab - Massage Therapy |
96% |
80% |
100% |
Rehab - Message Therapy |
< > |
< > |
49% |
Rehab - Physiotherapy |
43% |
22% |
44% |
Rehab - Resp Therapy |
17% |
6% |
3% |
Other - Midwifery |
100% |
100% |
100% |
Other - Naturopathic |
100% |
98% |
100% |
Other - Podiatry |
96% |
96% |
96% |
Green values are based on routinely collected data.
Blue values are based on estimates received from informed sources.
Red chevrons indicate a value exists, but data could not be obtained, or the data that was
received has been suppressed in compliance with research privacy policies
A third trend observed is that the proportion of providers who receive funding from non-public sources is often similar to the proportion of providers who exhibit structural characteristics commonly found in the private sector - such as being organized as a "for profit" entity. This value was almost always different from the proportion of providers for the same health service who engage in private sector delivery when viewed from a control perspective. (See Overview of Findings table above)
The findings confirm that the private sector plays an active and significant role in the delivery
of health services in Canada.
Recommendations
The purpose of the project is not to make recommendations regarding the nature or structure of private sector activity in Canada's health care system. It is simply to develop, to the extent possible, a high-level picture of what private sector delivery activities currently exist. The fact that data limitations make this so difficult to achieve leads to three key recommendations for consideration.
Recommendation 1
Policy and planning decisions that involve any health service where private sector delivery activity exists (and this report demonstrates that this involves all health services in Canada to some extent) will be compromised in the absence of a comprehensive suite of information describing the activities of private sector providers.
Mechanisms should be developed, in consultation with private sector providers, to ensure that private sector delivery activities are fully represented in Canada's national health databases.
Recommendation 2
While we were delighted to see the level of disclosure that was provided to the research team, it would be inaccurate to say that the private sector was eager to share any and all information that was sought. For example, while many felt comfortable sharing information regarding the relative proportion of revenues received from various sources, the disclosure of the dollar value of these revenue streams was a more sensitive issue.
Efforts must be made to build trust between private sector providers, data collection agencies, and the users of these data to ensure that the private sector is properly recognized as a significant participant in the delivery of health services in Canada.
A valuable first step would be to engage providers from service sectors with large private sector involvement (e.g., home care) in national data stewardship committee activities, or in other roles where they can provide input and leadership with respect to the development of routine data collection processes able to support provincial/territorial and national planning needs without compromising the positions of private sector providers.
Recommendation 3
Many private sector providers indicated an interest in seeing the development of routinely collected minimum data sets. It is expected that many private sector providers may lack experience with creating mechanisms for the routine collection of standardized data.
Organizations that already have this expertise (such as CIHI or Statistics Canada) should be provided the resources to facilitate the development of data collection capacity for private sector providers.
1 CIHI, 2004, Health Care in Canada 2004.
http://secure.cihi.ca/en.media, accessed Sept. 2004.
The views expressed herein do not
necessarily represent the views of Health Canada
The print version of the full report can be obtained in the language of submission from the Health Canada Library through inter-library loan.
