In this timely paper, Chodos and MacLeod review the most recent discussions in Canada on the role of the private sector in healthcare. Both authors are eminently qualified to lead this debate: MacLeod was an executive assistant to Senator Michael Kirby while the Senate Committee conducted its health study, and Chodos was one of the two full-time researchers assigned to the Senate Committee by the Research Branch of the Library of Parliament.

Chodos and MacLeod begin their paper by focusing their attention on the two major federal reports that were released in the autumn of 2002: the final report of the Senate Committee on Social Affairs (the Kirby report) and the Romanow Commission report. According to Chodos and MacLeod, these reports, on superficial analysis, represent two opposing viewpoints in the debate about the extent to which private sector involvement in healthcare in Canada should be expanded. In the Romanow report, for example, the perspective is generally that of the public system with no further expansion of the private sector role. The Kirby report is seen as more clearly advocating greater private sector involvement in healthcare delivery. After describing the basic premise of the two reports, Chodos and MacLeod proceed to argue that this polarization in the interpretation of views in the two reports is both "simplistic and inaccurate."

Using the similarities and the differences of the two perspectives, the authors analyze the extent to which the two viewpoints, public versus private, are currently reflected in the delivery and financing of the Canadian healthcare system and provide examples of where experimentations with private sector initiatives have taken place.

We are privileged in this issue of HealthcarePapers to have commentaries from individuals from a wide variety of backgrounds, thus providing rich discussion as well as diversified opinions. The eagerness of many individuals to respond to the lead paper on public versus private sector involvement in healthcare shows there is keen interest in the topic. It is clearly a subject of great importance to all Canadians.

Kenny begins the responses by raising the very real issue of value for money for the time, energy and dollars spent on analysis of our healthcare system over the last 20 years. The number of reports and recommendations produced federally and provincially is enormous and has probably cost millions of dollars. Kenny discusses the criteria whereby Canadians can judge the extent to which taxpayers' dollars have been well spent: there would be greater clarity regarding the goals of healthcare system reform; citizens would understand the issues better; federal-political "wrangling" would be closer to resolution; agreement on long-overdue efficiencies would result in obvious improvement; major disagreements about the way forward would also be clearly understood; and finally, accountability to Canadians for acting on recommendations would be a reality. In her discussion she raises the thorny issues of medically necessary treatments, fair share, and the idea that, in theory, public policy should reflect public values.

Also taking the perspective of the public, Bégin argues that the issue of "public versus private" in healthcare has not been thoroughly or sufficiently aired with the Canadian public. Despite the extensive cross-country town hall meetings and focus groups of the Romanow Commission, the public/private boundaries for healthcare in Canada have not yet been decided by Canadians. In Bégin's view, until the public has decided where the boundaries should be drawn little progress can be made in changing health policy.

Vertesi describes the public versus private debate as merely a proxy for the real issue, which in his view is market versus non-market behaviour. Vertesi comments on the Romanow report by saying "The title, after all, of Mr. Romanow's report is 'Building on Values' and he defends healthcare as 'a moral enterprise.' … Mr. Romanow is stuck on the type of ownership rather than the provision of care. But his moral argument is based on the need to pretend that decisions about something as sacred as health are not influenced, even when access is guaranteed, by something as crass as money." Vertesi indicates that Mr. Romanow is embracing a complete reliance on bureaucratic processes to anticipate and regulate all movement of goods, services and labour. He suggests that the difference between the two reports, then, boils down to a matter of belief systems that are almost religious in nature and not accessible to discussion. Consequently, reconciliation of the two reports is not possible no matter how close the other recommendations in the reports are, and no matter how much sensible people want that to happen.

According to McGowan, the case for change in Canada's healthcare system is profound and long overdue. In his view, there is a need to restructure the system, which was not designed to deliver the kinds of services needed. There is clearly a need to increase efficiency and accountability. In McGowan's view and his considerable practical experience, private management can and should serve as part of a package of reform. If policy-makers continue to pretend that the private sector can't provide efficient high quality care, then the opportunity to use a whole range of effective management techniques and incentives will be lost. He raises the important question as to why politicians cannot take a stand on private sector management of healthcare. He refers to "American-Style Healthcare" as an approach that tends to frighten people and deters them from thinking about rational solutions. He gives little hope for apolitical solutions and describes healthcare as the third rail of Canadian politics.

Deber outlines the current different types of private sector involvement in healthcare, including the extensive not-for-profit services. She presents the argument that private sector involvement will not work in healthcare because competition among providers cannot exist under a single-payer system such as that in Canada. She concludes that introducing the private sector more than it is now is like trying to walk in two directions at once - in her view the debate is too rooted in ideology to get resolved.

Marchildon suggests that the debate over the ideological positions taken by the Kirby and Romanow reports could be clarified by looking beyond funding and also examining how services are administered and delivered. He points out that in our current system, healthcare services fall into three categories and three major coverage types: universal public coverage for medically necessary/required services; mixed coverage for drug care, home and long-term care; and private health goods and services. He suggests that there are few differences between the reports on issues of funding, but that there are significant differences on issues of administration.

So where do we go from here? Sinclair reminds us to look at history. He refers us to a speech made by Tommy Douglas in 1982 when he outlined plans for medicare for Canada and described two phases of implementation: the first phase of reform was to remove financial barriers to health services, which has largely been achieved: the second was to reorganize the system of services delivery, which has not yet been achieved despite the proliferation of provincial reports that have recommended major changes. We still need, in Sinclair's view, to develop a system or systems of healthcare that provide coordinated services to populations in communities.

Weatherill presents a very pragmatic view and comments that sustainability is the real issue at both the national and front-line levels. She refers to the cost gap - that is, the gap between what Canadians want or indeed expect from a health system and the amount of funding available. One of her day-to-day concerns, as a CEO is that she spends a great deal of time managing access to services through waiting lists. But she indicates that the real

underlying issue is the cost gap - where will the funding come from? She recommends that we consider expanding revenues and look at the potential opportunities where the private sector can help get better value for the dollars spent.

It is clear from both the lead paper and the commentaries that it is time for change, but is there the will to do so? As many writers have suggested, we focus on best practices, improving coordination of services and clarifying the various options. In my view that is simply not enough to make the changes necessary - it may be too little too late.

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