Vol. 12, no 1, March 2001

JOURNAL OF THE FIIQ

Critical problems:

urgent action

SpecialReport:

ClairCommission

InterviewAn ever-changing

network

SolidarityThe Haitian

people carry on the struggle

An important eye-opener

March 8:follow-up

to theWorldMarch

More than everb

strongstrongand determinedand determined

March

82001

99548_Act_2001_ang 01/03/01 19:43 Page 1

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Attention - AttentionIs your gross annual employment income higher than 50 500$ for the year 2000? When a nurseis victim of a work injury giving right to an income replacement indemnity (IRI) paid by virtue ofthe Act Respecting Industrial Accidents and Occupational Diseases, Article 23.19 c) of the col-lective agreement stipulates that the employer must pay 90% of her net salary until the date ofthe consolidation of her injury. According to the law, the calculation of the income replacementindemnity is based on the gross annual employment income, up to the maximum annual insur-able earnings of 50 500$ for the year 2000. If her salary is higher than this maximum, theemployer must then pay the difference between the indemnity to which she is entitled by virtueof the collective agreement and that paid according to law. It is important to check your pay slip closely!

Vol. 12, No. 1, March 2001FIIQ Actualités, the journal ofthe Fédération des infir-mières et infirmiers duQuébec (FIIQ), is publishedthree times a year, with a cir-culation of 45 000 copies.

■ Conception and writing:

Journal Committee:Michelle Choquette Marielle Ruel

Communication-Information Service:Danielle CoutureMicheline Poulin

Executive Committee member:Régine Laurent, Secretary

■ With the help of:Consultants:Lucille AugerRichard BeauléMarie-Andrée Comtois Lucie Girard Thérèse LaforestLucie MercierHélène Tanguay

■ Translation:Martine Eloy

■ Secretary:Céline BourassaChantal Roy

■ Graphics:Josée Roy, graphiste

■ Photography:Jacques Lavallée

■ Printing:Caractéra

ISSN 1203-9837

In contactCritical problems: urgent action 3

On the cover page Photography by

Jacques Lavallée, World March

Solidarity

The Haitian people carry on the struggle 10An important eye-opener 11Pension Attention 12

The workload … something must be done 4

Status ofWomenMarch 8:a follow-up to the World March 5The recognition of thevalue of jobs: a struggle on many fronts 6Special Report:Commission Clair

A process involving everyone 7Reminder of the mandate 7One team, varied expertise 7InterviewAn ever-changing network 8

99548_Act_2001_ang 01/03/01 19:45 Page 2

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A ministerial commitment isneededIn the past years, whileexpectations and needs withregard to nursing care weregrowing, there was a con-siderable rollback in nursingpersonnel in the health-carenetwork. On several occa-sions, the FIIQ denouncedthe glaring lack of govern-ment planning with regardto the nursing workforceand demanded that the gov-ernment quickly introducemeasures for true planningbased on foreseen quantita-tive and qualitative needs fornursing personnel.

In fall 1999, the Minister ofHealth and Social Servicesset up the Forum nationalsur la planification de lamain-d’œuvre infirmière,and the FIIQ joined this taskforce on the Minister’s invi-tation. On January 25,2001, the forum presented avoluminous report and ahighly detailed plan of actionto the minister in order totake action with regard tothe alarming and disturbingdiagnosis concerning nurs-ing workforce needs. Whatis this diagnosis? "If we donot train approximately1000 additional nurses eachyear, in 2015 there will be ashortage of approximately17,500 nurses to respond tothe needs." How did this sit-uation arise while, in themiddle of the nineties, thedecision-makers of the net-work claimed that there wasa surplus of nursing person-nel?

If there is no importantchange in the organizationof work and current profes-sional practice, in the fac-tors of attraction to the pro-

fession and retention ofexisting personnel, thereport of the Forum statesthat "instead of retreating,the current shortage ofnurses will continue togrow, which will lead to amajor crisis."For many years now, and inparticular during the lastnegotiations, the FIIQ hasconstantly alerted the stake-holders in the network to theimportance of taking actionon these factors. What isnew is that all the actors ofthe network now share ourviewpoint. The FIIQ pushedfor the plan of action to bemore than a series of gener-alities and pious wishes, anddemanded that it be detailedenough to enable all theactors concerned to beclearly informed of theobjectives sought, theresults expected and theactions to be initiated inorder to reach these objectives.

Many of the strategies andactions identified by theForum were raised in a doc-ument prepared and pre-sented by the FIIQ to thisgroup; this document faith-fully reflected the problemsand solutions raised bynurses during the negotia-tion consultation.

All the members of theForum clearly indicated tothe MSSS decision-makersthat, if there is no energeticplan of action based on thecooperation and involve-ment of all the stakeholdersconcerned, "the situation ofthe nursing workforce,which is already difficult,will become even more so,compromising the capacityof institutions to preserveaccess to care and the qual-ity of services."

In order to ensure true, con-tinuous planning of thenursing workforce, partner-ship is required at all levels:provincial, regional andlocal. However, the keyactor for the success of thisplan of action is undoubted-ly the Minister of Health andSocial Services. This is why,when presenting their reporton nursing workforce plan-ning and their plan of action,Forum members formallyrequested from the Minister"a clear, political and finan-cial commitment to supportthis plan of action and itsimplementation."

From the very beginning,the FIIQ took an active partin all the work conducted bythe Forum. The major con-tribution of the FIIQ on thisissue is a testimony of oursupport, cooperation andexpertise. Can nurses alsocount on the same supporton the part of the Minister,on her promise to shoulderher responsibilities in thisfield, on a clear, political andfinancial commitment on herpart to reach the objectivesclearly identified in thisreport?

The Minister must under-stand that the situation iscritical and that it is urgentthat action be taken,because, need we repeat,the contribution of nurses iskey to the proper function-ing of the Quebec health-care system.

Jennie SkenePresident

Critical problems…

Urgent actionThe FIIQ will be pro-activethis year in implementingsolutions to the problems

of workload, nursing short-age, rise of violence in theworkplace and will take allpossible measures to forcethe government to conduct

a non-sexist job evalua-tion. There are important

issues to which theFederation will have to

devote time and energy.Just think of the transfor-

mations of the networkthat will result from the

recommendations of theClair Commission and the

People’s Summit that callson progressive forces to

resist the negative effectsof globalization. Thinkalso of the exploratory

process that the FIIQ hasundertaken with the FTQ

(Quebec Federation ofLabour) to study the possi-

bility of structural rap-prochement between our

two organizations.Moreover, important

issues are currently beingdiscussed at the National

Forum on NursingWorkforce Planning with

regard to the nursingshortage, which could

result, if nothing is done,in a major crisis for the

health-care network andcompromise access tohealth-care services.

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Since its creation, theFIIQ has always been

concerned by theproblem of nurses’

workload. In the faceof the real aggrava-tion of this problem

in the past years, thisconcern has become

all pervasive.

In this context, it is encour-aging to note that the modi-fication of Article 40 in thenew collective agreementreinforce nurses’ power tointervene and obtain a set-tlement on this question.Indeed, local teams whoavailed themselves of theprovisions of this article todate won the implementa-tion of interesting measuresto solve workload problemsin their institution. In certaincases, they obtained theaddition of nurses andsometimes of other cate-gories of employees, ormodifications in the organi-zation of work.

It is clear that to obtain suchgains, it took not only agreat deal of determinationon the part of local teams,but also an enormous quan-tity of work. These localteams could speak at lengthabout the difficulties theyencountered when gatheringevidence to prove the exis-tence of a workload problemin their institution, to pro-pose avenues of solution toremedy this and to ensurethat the solutions chosenare implemented.

Many local teams decided totake action to solve a work-load problem and favourabledecisions were issued bythe arbitrator in severalcases: Hôtel Dieu de Sorel,

Hôpital Laval, Hôtel Dieu deQuébec, Hôpital deMontmagny and the CHrégional de Rimouski. Otherworkload cases were settleddirectly by the Committeeon Nursing, namely at theInstitut de Cardiologie deMontréal, the MontrealGeneral Hospital, theCHUM-Pavillon St-Luc andthe CHUM-Pavillon HôtelDieu, and others yet weresettled by the resource per-son, as was the case at St-Mary’s Hospital andHôpital Charles-Lemoyne.

At Charles-LemoyneTwo departments won theircase before a resource per-son: the neurosurgery andneurology department, andthe orthopaedic and generalsurgery department. In bothcases, it took many hours ofwork to build the workloadcases. According to SylvieCoutu, nurse on the neuro-surgery and neurologydepartment, who worked onthis case, "it took a lot ofenergy, but it was worth it."Following the agreement,positions were posted for 2full-time nurses, 4 part-timenurses, 3 full-time and 4full-time beneficiary atten-dants on the three shifts.Moreover, additional equip-ment was added, such as: asuction machine and anoxygen flowmetre in eachroom, additional thermome-ters, single-dose vials,night-commodes, geriatricchairs, etc. As for the gener-al surgery and orthopaedicdepartment, Carole Miron, anurse who was involved inthis workload case, consid-ers that there has been con-siderable progress: four

nurse positionsand three bene-ficiary atten-dant positionswere postedon the threework shifts.Moreover, inorder to betterrespond to the needs ofnurses on the evening andnight shifts, the partiesagreed to revise the agree-ment in the spring at ameeting of the Committeeon Nursing.In meetings with theemployer on workload prob-lems, several problematicelements in the organizationof work were discussed anda certain number ofrequests were settled beforemeeting the resource per-son. In short, this is a highlyworthwhile process.

Training sessionsConcerned by the difficultiesencountered in gatheringproof for a workload case,the FIIQ drew up a trainingsession on this issue. All theinformation deemed essen-tial in building a workloadcase are discussed in thistraining session. Indeed, inthis session, participantslearn what is meant by aworkload problem, how toidentify the elements ofnurses’ workload, the crite-ria in jurisprudence used toprove the existence of aworkload problem, how togather the pertinent infor-mation to build a workloadcase, how to identifyavenues of solution and,finally, to ensure follow-upof the solutions chosen. Before closing, we muststress the importance of the

Council of Nurses in the set-tlement of workload prob-lems. By virtue of Article 40of the collective agreement,it is one of the responsibili-ties of the Council of Nursesto examine workload com-plaints. It is therefore impor-tant and urgent to set up aCouncil of Nurses in allinstitutions and to use suchcommittees when possible,not only to for workloadcomplaints but also to dealwith any question directlyrelated to nursing and workorganization.

Many nurses presently haveexcessive workloads and,given the nursing shortage,we can expect this problemto grow if appropriate andlasting solutions are notrapidly implemented. Thepresence of excessive work-loads certainly has an influ-ence on the attraction andretention of nurses in thehealth-care network, andthis is why, when a work-load problem crops up, it isimportant to do somethingabout it. Thérèse Laforest, consultant, Task andOrganization of Work Sector

The workload …something must be done

99548_Act_2001_ang 01/03/01 19:45 Page 4

October 14 rally.The government

may think it foundan easy way out by dis-

tributing a few crumbs,especially with regard to theelimination of poverty, butwomen’s demands are stillon the table and, sooner orlater, it will have to respond.

Women still have the dreamof the World March, thedream of a world free ofhunger and fear. The strug-gle we have undertaken isan enormous one: we haveundertaken to fight global-ization which promotesprofits at the expense ofpeople and the respect oftheir rights. Such a struggleis not won overnight. Thewomen of the 161 countrieswho participated in theWorld March know this. Thegovernment’s contemptuousattitude will certainly notstop women. We will contin-ue to march, from all cor-ners of the planet, withdemands adapted to ourrespective cultural realities.The awareness-raising workon the issue of globalizationand its impact on womenwill continue and intensifybecause, henceforth, werefuse to accept suchinequalities. What can agovernment do in the face ofsuch an awareness-raisingventure!

As we have seen, womenhave stood up against thenegative effects of globaliza-tion. So did the Federationat its 1998 Convention,which examined how thisphenomenon had an impacton nurses’ daily lives andaffected them as health-careprofessionals, unionizedworkers and women. Theprivatization of certain ser-vices is a very real threat. Asstated in the March 8 pam-

What a feat it was tobuild such a vast

movement todenounce poverty

and violence againstwomen! The Quebecwomen’s movementfaced this challenge

in an outstandingway with the large

rally on October 14.However, such mobi-

lization does not happen by magic. It is

based on intensive,relentless education

work, carried outthroughout the

network of Quebecwomen’s groups for

more than threeyears.

When women stand up,angry and determined tocarry an issue through tothe end, and express thiswith such dignity, some-thing changes for each oneof them and for women as awhole. The strength of suchmobilization makes thewomen’s movement anunavoidable force. This isthe most important gain thatQuebec women made following the marches in allregions of Quebec that culminated in the large

phlet, more and more often,economic concerns areoverriding health concerns.Each gesture, each test carried out in laboratories isexamined from a monetarypoint of view. The growingshortage of health-careworkers and the persistenceof casual employment haverepercussions on health services.

On International Women’sDay, the women’s move-ment hopes to pursue theawareness-raising work thathas begun. The theme callson the determination ofwomen in all walks of life topursue the struggle and toparticipate in a vast move-ment of solidarity in othermobilization activities, suchas the People’s Summit thatwill be held next April. Thissummit will precede theSummit of the Americaswhere 34 heads of state willbe present to discuss a free-trade area of the Americas.There are already a numberof indications that the com-mercialisation of educationand health-care is justaround the corner; this iswhy it is of prime impor-tance for nurses to mobilize.

A pressing call toremain strong and

determined

"We can’t turn backthe clock. We are

inflexible, unshakeable,immortal and hence-forth uncontrollable.

Our revolution is irreversible.

Do not forget this."

Hélène Pedneault:Manifesto for the

World March of Women

Let us take theopportunity tobecome betterinformed...● about the effects of

globalization on our livingand working conditions asworkers, nurses andwomen;

● about the measures to betaken to let our govern-ments know that they areaccountable to us forwhat is being done: thatpublic services are not acommodity and that theymust remain outside themarket.

As a follow-up to theWorld March of

Women,participate in theactivities of the

People’s Summit!Lucie Girard, consultantStatus of Women Sector

5

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Since its creation, the FIIQ has always considered the recogni-tion of the value of Nurse and Baccalaureate Nurse jobs to beone of its priorities. Indeed, the first round of negotiationsconducted by the FIIQ in 1989 led to a 9,2% repositioning atthe top of the scale and the introduction of the job title ofBaccalaureate Nurse with a distinct salary scale. The bargain-ing round that ended a year ago resulted in another salaryrepositioning for nurses and Baccalaureate nurses, and thepayment of a 3% lump sum for the period from April 1, 1999to March 31, 2000.Presently, the FIIQ continues its work with the Treasury Boardin view of proceeding to the evaluation of Nurse andBaccalaureate Nurse jobs and thus, being able tocompare them with the other jobs in the public andpara-public sectors. This study is provided for in thecollective agreement.In order to determine the value of jobs and theirrespective pay, the Quebec government set up at theend of the 1980s, a pay relativity programme. Theobjective of this programme is to establish the rela-tive value of jobs and to compare salaries. TheTreasury Board presented this programme to the PayEquity Commission and asked this body to declarethat its programme complies with the Pay Equity Act.The FIIQ, like other labour organizations in Quebec,explained to the Pay Equity Commission that thegovernment programme did not meet the obligationsimposed in the Pay Equity Act. The Commission didnot accept these arguments and ruled that the gov-ernment programme complied with the law, except-ing the mode of estimation of salary differences thatwas deemed discriminatory.The FIIQ intends to bring this decision to court.However, this does not mean that the FIIQ will stopthe work undertaken or proceed to the evaluation ofNurse and Baccalaureate Nurse jobs with the govern-ment tool. The FIIQ will continue the work undertak-en with the Treasury Board and demand that the jobevaluation process currently in progress be carriedout on the basis of the principles laid out in the PayEquity Act.The Pay Equity Commission’s decision does notmean that the Quebec government’s pay policy is notdiscriminatory with regard to predominantly femalejobs. Indeed, the Commission des droits de la per-sonne et des droits de la jeunesse (CDPDJ) is cur-rently examining complaints of pay discrimination.These complaints, filed before the coming into effectof the Pay Equity Act, submit that the Quebec gov-ernment contravenes the Quebec Charter of HumanRights and Freedoms since its pay policy is discrimi-natory with regard to jobs occupied mainly bywomen. These complaints concern a vast array of jobtitles, including the job title of Nurse andBaccalaureate Nurse.

In order to determine whether the government pay policy isdiscriminatory, the CDPDJ must conduct an inquiry on thesevarious job titles. Indeed, in order to be able to conclude thatthe government pay policy is discriminatory, it must be shownthat the discrimination is generalized and systemic, and that itaffects several job titles. The FIIQ follows the progress of this file withgreat interest, not only for the nurses it represents but also for all Quebec women.Richard Beaulé, consultantNegotiation Sector

The recognition of the value of jobs: a struggle on many fronts

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99548_Act_2001_ang 01/03/01 19:46 Page 6

COMMISSIONClairClair

SPECIAL REPORT

1

A LONG-AWAITED REPORT

Since the beginning of the work of the study commission onthe health services and social services, the Clair Commission,the FIIQ took part in all available forums to voice the viewpointof nurses. In various regions, during the provincial hearings, aswell as in public events, we reasserted high and loud nurses’attachment to the public health-care system.

In our statements and comments, we stressed that nurses’ pro-fessional skills were underused and that the optimal use ofnursing potential was essential in order for the health-care sys-tem to be able to meet not only today’s needs, but also theneeds of tomorrow. It was clearly shown that changes must bemade in the Quebec health-care network because there are fartoo many problems.

The FIIQ reacted favourably to the importance granted, in termsof political orientation, to the issue of prevention and publichealth in the Clair Report. Moreover, we agree with the portraitdrawn by the Commission on the state of discouragement of thepersonnel working in the network. However, we clearlyexpressed our concern with regard to certain proposals onhuman resources designed to counter this situation, but that, inour opinion, will not improve the situation. The Federation alsocriticized the fact that there was no mention in the report of thesituation of women, in particular as workers and naturalhelpers.

At the time of going to press, we still do not know what will bethe reactions of the Minister of Health and Social Services to theClair Report. We hope that it will lead to recommendations thatinclude solutions advocated by the Federation. Regardless ofthe changes or transformations that could take place in thehealth-care network, it is clear that we will continue to demandsolutions to the problems experienced by nurses, uphold themaintenance of a public, accessible and comprehensive healthsystem, and demand that the government invest the requiredfunds.

Jennie Skene,President

99548_Act_2001_ang 01/03/01 19:46 Page 7

The bases of the health and social services network: constantly requestioned

2

Some thirty years after its creation, the Québec health and social services system continues toraise many questions and controversies. This phenomenon is not exclusive to Québec. Thus, a reportby the World Health Organization (WHO) published last summer discussed a third generation ofreforms in the majority of approximately 190 member countries.

This permanent debate is explained by the complexity of the questions to be dealt with and by thesocial, and especially economic, interests that are at stake. How can access be guaranteed to qualityservices, without distinction of income or place of residence? How can it be assured that all citizenscontribute equitably to the collective funding of these services? What can be done so that the servicesprovided really contribute to improving the health of the entire population, without distinction ofincome, place of residence, gender, ethnic origin or social status? These are all challenges for whichthe solutions must always be reinvented in a changing social, economic, political and technologicalcontext. Here is a brief review of the various phases of the public debate in Québec that started in the 1960sand is reflected today in the Study Commission on Health Services and Social Services.

Establishment of the health-care system we know today on the basis of the five Canadian principles:accessibility, universality, public administration, comprehensiveness and portability. Elimination of healthunits, creation of 71 CLSCs, 31 Community Health Departments (CHD), 11 Regional Councils of Healthand Social Services (CRSSS), the Office des professions, the RAMQ, the Department of Social Affairs andprofessional corporations.

The Rochon Report was not applied immediately. It instead gave rise to another vast consultation processorganized by the Minister of Health at the time, Madam Lavoie-Roux. However, the main recommenda-tions of the Rochon Report were taken up by the Minister of Health who succeeded her, Marc-Yvan Côté,who drafted the new Act respecting health services and social services on the basis of Bill 120: elimina-tion of the 11 CRSSS and creation of 18 regional boards, integration of the 30 CHDs into the regionalboards, redefinition of institutional missions, etc. The drafting of the health and well-being policy can also be seen as one of the major spin-offs of theRochon Report.

Deinstitutionaliztion, non-institutionalization and parental empowerment were the main spin-offs fromthis report.

Partial completion of the CLSC network by the merger ofnew CLSCs with other types of institutions (total of 170CLSCs out of the 200 initially planned) and reorientation ofCLSC services based on national priorities that focus actionson the groups at risk: children and families, troubled youthand adults living with mental health problems. According tothis report’s recommendations, all CLSCs must deliver gener-al medical services and psychosocial services in the eveningsand offer a telephone service at all times.

Bill 33 on prescription drug insurance. The refusal to institute universal insurance and the decision to institute aco-payment plan funded by premiums had the effect of privatizing prescription drugs for seniors and people onsocial aid while providing coverage for other people who do not contribute to a private insurance plan.

Received by the Minister of Health and Social Services, thisreport did not result in official changes. It was used insteadby the government as a reference for the ongoing debates.The assertions that the network was not being privatizeddespite the increase in the private share of funding for ser-vices and the claims concerning the system’s non-viabilitywere repeated without change in government’s documentsand in those produced by the Clair Commission.

As we go to press, the Minister has not yet commented onthe report.

1967-1973 : Commission of Inquiryon Health and Social Welfare, whichled to the Report of the Castonguay-Nepveu Commission.

1985-1987 : Commission of inquiryon health and social services, whichled to the Rochon Report.

1987 :■ Committee on mental health

policy, which led to the HarnoisReport.

■ Committee on reflection and analysis of the services provided by CLSCs, which led to the BrunetReport.

1994 : Committee on revision of theoutpatient circular that led to theDemers Report entitled De l’assis-tance à l’assurance (From assistanceto insurance).1996 : Committee of experts on pre-scription drug insurance which led tothe Castonguay Report entitled Desvoies de solutions (Possible solutions)

1998-1999 : Working group on thecomplementarity of the private sector in the pursuit of the basicobjectives of the public health-caresystem in Québec, which led to theArpin Report.

2000-2001 : Study Commission onHealth and Social Services, whichled to the Clair Report in 2001.

Needless to say, the government doesnot always rely on the reports result-ing from consultations to introducechange in the network. In somecases, it proceeds by parliamentarycommission, such as the Commissionon the funding of the network which,in 1992, resulted in the privatizationof optometry services for adults anddental services for children under 12years of age, or the recent parliamen-tary commission on the evaluationreport on the general prescriptiondrug insurance plan, which led to substantial increases in the financialcontribution of insured persons.

At other times, without any form ofconsultation, the government hasimposed major changes, such as performance-based managementstandards, the shift to ambulatorycare, closures, mergers and changesof mission, not to mention the budgetcuts in pursuit of the zero deficit. But it nonetheless remains that thecommissions and study groups are aprivileged opportunity to debate thefuture of the health-care system publicly.

99548_Act_2001_ang 01/03/01 19:46 Page 8

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The Clair Commissiontherefore received the points ofview of experts, partners andorganizations of the health andsocial services network on thefunding and organization ofservices. The regional boardswere then mandated to imple-ment means allowing the pub-lic and organizations of aregion to express their viewson these questions. Moreover,at the end of the exercise, theywere to deposit a summaryreport with the commissioners.The FIIQ therefore participatedactively in the various availableforums: meeting of experts,small group discussion withthe Commission’s members,presence at the Commission…

The form this consultation tookin each region of Québec variedwidely: forums and discussionworkshops, oral and writtenopinions with the possibility ofa hearing, surveys, etc. Insome regions, people couldcomplete questionnaires, whileothers could use a toll-free line.The print and electronic mediawere involved and it was evenpossible to transmit opinionsdirectly to the Clair Commissionvia the Internet.

To help the affiliated unionsprepare properly and favourtheir participation in the ClairCommission’s activities, theFederation organized a two-daytraining session in mid-September. The union presi-dents were able to study thereference documents issued bythe Clair Commission and ana-lyze the issues together.

Jean Denis, Professor with theHealth AdministrationDepartment at the Universitéde Montréal, was the guestspeaker for this occasion. Heshared his analysis of the situ-ation prevailing in the networkand the possible alternative. Inthe light of the informationreceived at this meeting, sever-al unions participated activelyin the Clair Commission. FIIQActualités has obtained theessential points of the messageconveyed by some unions.

Affiliated unionsvoice their opinionsIf the Minister of Health andSocial Services, Mrs. Marois,was hoping for support fromthe public or organizations fora continued moved towardsprivatization, the exerciseinstead served to denounce theprivate sector’s already exces-sive presence in the network.While the Syndicat profession-nel des infirmières et infirmiersde l'Estrie (SPIIE) declared itsopposition to any form of pri-vatization, the Syndicat desinfirmières du nord est québé-cois (SINEQ) denounced itsunderhanded effects and calledinstead for investments toimprove the public network.The Syndicat des infirmières etinfirmiers du Centre hospitalierrégional de l'Outaouais(SIICHRO) warned theCommission against the dan-gers related to deinsurance ofservices. This union does notbelieve in a uniform solutionfor the organization of services.Each region has its own char-acteristics that must be takeninto account. The Alliance desinfirmières de Montréal (AIM)emphasized the importance ofcompleting the reform. The

from related tasks that take uptoo much of their time so thatthey can dedicate themselvesfully to the tasks for which theywere trained.

The reform of the network thatbegan in 1995 achieved theobjective of reducing the num-ber and length of hospital staysbut stopped there. Both theSPIIQ and the SINEQ empha-size the importance of invest-ing sufficient financialresources to make better use ofthe CLSCs. The AIM points outthat the necessary investmenthas never been made in thecommunity and in the CLSCsto assure the continuum ofcare. The SINEQ calls for agreater number of LiaisonNurse positions, while theSPIIE sees nurses as the hubof a multidisciplinary network.The SIICHRO believes it isessential to have better con-certed action on primary ser-vices between the emergencyrooms, the CLSCs and doctors’offices. The introduction ofneighbourhood clinics ought tobe explored.

In general, the remuneration ofphysicians has raised ques-tions both on the part of thepublic and of some union rep-resentatives. The status quo isunacceptable and some call onthe government to show thepolitical courage necessary toput an end to fees for serviceand the granting of all kinds ofprivileges. Physicians mustintegrate into the public healthand social services networkand the multidisciplinaryteams, says the SINEQ.

Michelle Choquette, nurse

Sustained FIIQ presence at the Clair Commission

WILL THIS EXERCISE HAVE HELPED TO GUIDE THE DECISIONS?

The union presidents who intervened in this public debate are unanimous insaying that they had the impression they were heard by the regional boards

and the commissioners when they were present in the regions. They alsoheard other people express their views on the urgency of doing things differ-

ently, without referring to privatization as does the facilitation guide thatserved as the basis for discussion for these consultations. If the government

turns a deaf ear to nurses’ comments and demands, this would be a very awk-ward political move, but above all, it would be very disturbing for the future of

the health and social services network.

Syndicat professionnel desinfirmières et infirmiers deQuébec (SPIIQ) called forregionalized budget envelopesthat consider the regions’ realneeds.

The unions that participated inthis consultation took theopportunity to reaffirm the values that must continue to bethe basis of our health-caresystem: EQUITABLE, FREE,ACCESSIBLE AND UNIVERSAL.

If there is one point of consen-sus among the unions thatissued the opinions, it is toallow nurses to occupy theirfield of competency fully.Making better use of nurses’education and experiencewould make it possible forthem to teach, inform andaccompany patients. The factthat too little time is spent withthe patients increases the levelof anxiety and contributes totheir hasty return to the sys-tem. Where is the saving?When a person needs care, heor she needs to be informed,reassured and cared for: toknow what is happening andwhat will happen. This is oneexample of the kind of workthat nurses are capable of per-forming and that would bringabout significant changes inthe network.

To improve the quality of ser-vices, it is important that nurs-es be able to intervene moredirectly with individuals. Thismeans doing everything possi-ble so that delegated acts andintervention protocols bettercorrespond to the realities ofdifferent communities. Thisimplies that nurses be freed

Last June, the Minister of Health andSocial Services announced the

formation of the Study Commissionon Health Services and Social

Services by introducing its Chairman,Michel Clair, who had previously

served as PQ Minister of Revenue,Transport, Energy and Resources,Chairman of the Conseil du trésor,

Executive Director of the Associationdes centres d’accueil et des centres

de réadaptation du Québec, and VicePresident and President of Hydro-

Québec subsidiaries. Along with eightother colleagues, he was mandated

“to propose to the government, aftera public debate, means for meeting

the challenges that currently face ourhealth and social services system”.

This Commission therefore was to“receive the points of view of the

public, the network’s partners, repre-sentative organizations and special-ists on the two themes related to itsmandate: funding of the system and

the organization of services”.

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These issues must be considered in a context of neo-liberal globalization where largecompanies endeavour toreduce regulations in sectorstraditionally under State con-trol, to bring them into thesphere of the free market andthus transform into a commod-ity the right to health entrench-ed in the Declaration of HumanRights and taken up, in manyplaces, in Quebec law.

It is this type of abusive prac-tice, which would be mostdamaging for human and eco-nomic development in Quebec,that the Fédération des infir-mières et des infirmiers duQuébec is working to counter.This is why the Federationreasserts that it supports thefundamental principles of thehealth-care system and optsfor equitable funding by all citizens, regardless of theirhealth status, by way of incometax, which is a progressive taxand, consequently, the fairestform of contribution despite itsshortcomings. It is on thebasis of these arguments thatwe reject the options of specialfunds, a user fee or deterrentfee, and tax credits for invest-ments that serve to fund private clinics. However, incertain particular circum-stances, there is a slight open-ing to the principle of a healthincome tax. However, in thedifficult context that currentlyprevails, we cannot go alongwith the sale of services tonon-residents.

As opposed to what is general-ly believed, Quebec does notspend a lot for its health sys-tem. However, the fact thatthese amounts are distributedin three distinct budgetaryitems is an obstacle to the pro-ductivity of the initiatives takenin specific networks. Thus, wesupport the idea of merging thebudgets of the Ministère de laSanté et des Services Sociaux,the Régie de l’assurance-maladie and the Régie de

l’assurance-médicaments andof granting budgets on aregional basis, while respectingfreedom of choice regardingthe place of care and care-givers. According to the FIIQ,MRCs cannot be considered asworthwhile actors in the healthand social services sector. Onthe other hand, CLSCs mustreceive funds in accord withthe role entrusted to them andthey must play a major role inthe delivery of services.

On the issue of the organiza-tion of services, it is erroneousto claim that the private sectoris better than the public sector.This assertion proves true forvarious forms of privatization:hospitals, private insurers, pri-vate clinics and the deterrentfee. Various research studies,mainly American, concludedthat costs rise when privateservices are introduced;administrative costs doublewhen privatization settles in;waiting periods grow longerwhen surgeons operate both inthe private sector (private clin-ics) and in the public sector,and excessive services are pro-vided when equipment is avail-able on site; finally, the intro-duction of a deterrent fee limitsthe use of services and leads tonegative results and expensesin other areas where servicesremain free. This is why weargue that services mustremain public. We must notforget that impartation or con-tracting out, experimented incertain Quebec institutions,resulted in failure. In a sectorof activity where the labourforce is the main component,what else can we expect but adeterioration of working condi-tions and a rise of unemploy-ment? Furthermore, the FIIQsupports community groups intheir demands for autonomyand funding.

In the past 20 years, the rangeof insured services has con-stantly been reduced. How canthe study commission proposeadditional sacrifices, whenexperience shows that the pri-vatization of services will leadto a rise in costs. The FIIQdemands that home-care ser-vices that have been sacrificedwith the shift to ambulatorycare, despite political commit-ments, be once again includedin the list of insured services.The same applies for relief-respite services and supportservices in the home that helpto keep health-impaired peoplein the community.

As for doctors, the problem isnot one of shortage but ratherof poor geographic distribu-tion. The new mode of remu-neration for physicians shouldbe closely linked to the rolethey are expected to play. Inthe roles with which they areentrusted, these responsibili-ties should not contribute tomedicalize health problems.

It is increasingly acknowledgedthat a better use of nurses’ pro-ficiency would lead to a moreefficient and productive organi-zation of health and social ser-vices. Whether with regard tothe identification of health-careneeds, prevention, teaching orthe follow-up of clienteles,nurses can achieve positiveresults with regard to the quali-ty of care, the reduction of thelength of stays and satisfactionat work, regardless of the typeof institution. In particular infirst-line care, nurses canassure the follow-up of per-sons with various pathologies,besides working in the fields ofhealth promotion, preventionand education, and helpingbeneficiaries to take charge oftheir own health. Thus, theFIIQ is favourable to the development of new roles withan extended field of practice,including that of nurse practitioner.

A network that reflects our expectations and collective values

In its brief, the FIIQ first identifieswhat it considers to be the issuesat stake for the health and social

services system in the comingyears. The first of these issues

concerns the improvement ofhealth and the importance of trying

to predict the possible impacts ofthe reforms on the health of the

population concerned.The second issue, the question of

responding adequately to citizens’expectations, is critical given thatthere is strong pressure from thehealth industry to open the door

even wider to privatization. In thisrespect, it is true that the phenom-

enon of the aging of the popula-tion, with related pathologies and

impairments, constitutes a consid-erable challenge; however, it mustnot be seen as a dreaded catastro-phe. Other possibilities must also

be considered for the improvementof health by promotion and preven-

tion, and other phenomena, likepoverty, must be checked. This is

not to mention the influence oftechnological developments on thehealth-care system and the effect,

in terms of demands, that betterpublic information may engender.

The third issue, the fair distribu-tion of the responsibility for the

funding of the health services, isthe most crucial because the

debate on this is based onunavowed ideological premises

that can considerably change thefuture of the network.

Finally, the last issue, that offinancial viability, rests on the

population’s capacity to financecollectively a health-care systemthat meets the expectations and

needs of the population as awhole. This is where the aging of

the population is presented as "a worst-case scenario" and the

debate becomes highly ideological.

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Clair Commission Report:outstanding points… our reactions

The Clair Commission Report, entitled Solutions émergentes (emerging solutions), was made public onJanuary 17, 2001. In all, it includes 36 recommendations and 59 proposals. The Clair Commission adoptsthe new model put forward by the World Health Organization (WHO): to make choices and to perform.This model is the foundation of its report. The commission considers that these two obligations resultfrom the limited availability of resources. Prevention and public health are seen as unavoidable ele-ments; however, the mode of funding is not discussed. As we will see later on, the Commission chosethe worst-case scenario. The Commission went a little beyond its mandate on the organization of services

and funding, by taking a position on the question of human resources and governance.

ORGANIZATION OF SERVICES■ Creation of Family Medicine Groups (FMG)■ First-line social services in CLSCs■ Integrated services network■ Affiliation of specialized clinics to hospital centres■ Enrichment of the nurse’s role and recognition of nurse practitioners

Family medicine groups (FMG)would be composed of groupsof general practitioners, togetherwith clinical nurses or nursepractitioners. Nurses, dispatch-ed by their CLSC employer towork in FMG, would participatein taking charge and coordinat-ing services to a determinedgroup of citizens, between1000 and 1800 men andwomen.

The FIIQ has been demanding for quite some time that nursing practice be expanded. It insistentlydemanded, among other things, that nurse practitioners be granted true professional autonomy, with-in collaborative practice, and that their field of practice be clearly delimited in order that they be ableto perform professional acts, at the diagnostic and therapeutic levels, as well as in regard to patientfollow up, while respecting a professional field that remains to be defined since the role of nursepractitioner is not yet recognized. The setting up of a training programme for nurse practitioners willundoubtedly require some time and the arrival of a first cohort could take several years.

However, there are already experienced nurses who work in family medicine clinics and in CLSCs.When the Clair report proposes that the FMGs be composed of clinicians known for their expertise, theFIIQ believes that it also recognizes the pertinence of having recourse to nurses who are alreadyworking in first-line care.

Integrated services networks would be set up by regional boards forspecific clienteles: elderly people in the process of losing autonomy,mental health, persons suffering from complex, and often chronic,diseases (e.g. COLD, heart failure, Alzheimer, asthma, diabetes).

The objectives of the introduction of integrated networks consistin better access and better continuity of services. However, therewould not be any single model. The networks proposed differ onaspects of clinical and financial responsibility; local, regional andeven provincial coordination, and professional coordination _physicians, nurses or other professionals. This is something tofollow closely.

The affiliation of clinics of specialists to hospital centres would offer,on an outpatient basis, diagnostic and therapeutic interventions.These clinics would become an operational extension of the hospitalcentre. Physicians would be attached to a clinical service, would beunder the authority of the head of service, would be subject to thesame standards and would participate in the Council of Physicians,Dentists and Pharmacists. Affiliated offices would offer medicalconsultation services, outpatient clinics, certain diagnostic tests(e.g. medical imaging) or certain minor surgeries or day surgeries.The funding would be public and physicians would be paid by theRAMQ. As for other resources, their "administration [… would be]under the sole responsibility of the physicians."

What does this mean? That human resources, especially nurses,would no longer be part of the public health network? Thus, ser-vices financed with public funds would operate with a privateworkforce. The FIIQ can only fear for the working conditions andsalaries of these persons, especially since these clinics have anenormous potential for expansion, when we know that 80% ofsurgeries are now performed as day surgeries.In support of this orientation, the Commission stresses betteraccess to services, shorter waiting lists and reduced demands onoperating rooms. However, American studies demonstrate with-out the shadow of a doubt that public administration constitutesthe best investment. The arguments outlined in the brief submit-ted by the FIIQ and taken up in this publication explain this atlength. Though very pertinent, it seems that these argumentswere discarded by the Commission.

THE HEALTH-CARE NETWORK ACCORDING TO THE CLAIR REPORT

OUTSTANDING POINTS

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HUMAN RESOURCES■ Introduction of a continuous workforce planning process ■ Preponderance of the competence criteria for the granting of positions■ Slimming down of regulations and reform of the Professional Code■ Local negotiations: schedules, replacements, presence at work, management of positions■ New definition of mobility

We must aim at "developingproficiency, reviving pride."Negotiations should be decen-tralized on certain subjects topromote the appropriation atthe local level of questionsrelated to the organization ofwork.

The Commission draws a very realistic portrait of the feeling of discouragement among the personnelworking in the health and social services network. It is unfortunate that the Commission took up thelitany of the "rigidity of collective agreements", so dear to employer associations, without consideringthe innovative approaches developed by the FIIQ in the field of the organization of work. The sameapplies to the decentralization of negotiations on these subjects. Yet, all those who, at one time oranother, participated in a local project on the organization of work, know full well that action on theorganization of work cannot be restricted solely to the aspects provided for in the collective agreement.

FUNDING■ Vulnerability of tax funding and maximum limit on public funding ■ Wider coverage of services by group insurance plans■ Review of the services, new technology and drugs offered■ Adoption of a framework policy for partnership with the private sector and the tertiary sector ■ Provincial investment campaign■ Creation of an insurance plan against the loss of autonomy

THE STRATEGIC ROLE OF HUMAN RESOURCES

An "old-age fund" would be setup. It would be funded by apre-determined compulsorycontribution, in addition toincome tax. Companies wouldnot contribute. The plan wouldensure all those people whohave a long-term loss of auton-omy _ 6 months and more _ oronly the elderly. Home ser-vices would be offered in kindor paid for.

The Clair Commission chose the "worst-case scenario", that is the hypothesis according to which thegrowth of the population 65 years and over, and technological development would literally lead to thebankruptcy of the health and social services system, if no measures are taken. Therefore theCommission, that shares the "economic" ministers’ viewpoint in the Quebec government, proposesthe setting up of an "old-age fund," a kind of cigar-box in which funds can accumulate (capitalizedfund) to face the ageing of the population. The maintenance of the general income tax rate wouldprobably have made it possible to constitute this kind of fund with government surpluses. Instead, thegovernment prefers to lower the rate of income tax, and then has recourse to a measure that will costproportionally more for the poor (a regressive tax). Especially since low-income people generallyhave a lower life expectancy and are therefore less liable to profit from their investment. The pro-posed mode of funding thus appears to be inequitable. The FIIQ would have preferred that theCommission propose a mode of funding that increases proportionally to income (progressive tax).

HOW SHOULD THE NETWORK BE FUNDED?

OUTSTANDING POINTS

OUTSTANDING POINTS

We need to "redefine mobility" according to contemporary realitiesand allow mobility of personnel offering services to a given popula-tion. Mobility within the same institution, between affiliated certifi-cation units and between different institutions would be desirable.

The Commission proposes a solution before having even identi-fied the problem. As a matter of fact, the Commission deploresthe lack of strategy in the area of human resources developmentand the instability of regular work teams: how can we hope to cor-rect this situation by promoting mobility?

In order to value proficiency,the process for granting positions will be modified toacknowledge the preponder-ance of the competence criteria.

The delivery of care should beorganized in a more flexiblemanner and the role of nursesshould be expanded.

Before finalizing its report and asserting that it is necessary to change the process for the granting ofpositions to promote competence, the Clair Commission should have consulted the collective agree-ments in effect in the network. Indeed, the texts of the collective agreements stipulate that, to obtaina position, the first criterion is to meet the normal requirements of the job. It is only after, that seniority comes to play.

In the brief it presented to the Clair Commission, the FIIQ stressed the under-utilization of the compe-tence and skills of nurses, and the capacity of the latter to do more and better, providing adequateconditions of practice are provided. To this effect, the Federation insisted on the importance of in-service training and the introduction of measures to relieve nurses of certain duties that can be per-formed by others, for example beneficiary attendants. As a matter of fact, several workload problemshave been improved by adding support staff. This is to say that the improvement of nursing care oftendepends on the possibility of making time for the delivery of care itself. Thus, the substitution of otherresources to give nursing care, such as is implicit throughout the report, is not the solution. TheFederation hopes that when the Commission states that a "considerable part of the duties [of thenurse] could be performed by other categories of personnel, with less training, at a lower cost, andwould be of comparable quality", it refers to those duties that are not directly related to care and thatcould advantageously be entrusted to beneficiary attendants, for example.

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Almost all the members ofboards of directors of institu-tions, regional boards, citizens’forums and the Quebec agencyor health insurance corporationwould be appointed.

The Clair Commission report proposes substantial changes in the governance of the health-care system. Thus, positions on the boards of directors at all decision-making levels would be filled byappointment. It is clear that, from the beginning, the electoral process in the health-care network hadseveral shortcomings. Nevertheless, does this mean that all administrators, with but a few excep-tions, should be appointed by a higher administrative level? Should we fear, as the Auditor General ofCanada recently denounced in the case of Federal agencies, that partisan influences take precedenceover the managerial skills of these administrators? This is undoubtedly a legitimate concern.

SHOULD WE FEAR FOR DEMOCRACY?

PRIVATIZATION■ "Commodities", "consumer goods among others"■ "new universalism", "essential services"■ Framework policy for partnership with the private sector and the tertiary sector ■ Quebec-wide investment campaign

GOVERNANCE■ Creation of a Quebec agency or health insurance corporation■ Appointment of the members of the board of directors of regional boards■ Creation of a citizens’ forum in each region ■ Creation of a regional nursing commission in each region■ Unified board of directors for first-line institutions■ Recognition of community groups, social economy corporations and cooperatives

OUTSTANDING POINTS

OUTSTANDING POINTS

The government and citizens should recognize the vulnerability oftax funding in two ways: by establishing "limits on the maximumacceptable level of public expenditures" and by giving the network athree-year budgetary framework.

The role of "natural helpers", whose contribution is priceless especially since the beginning of theshift to ambulatory care, is almost ignored in the report. The only mention of "natural helpers" was tosay that it would be one of the roles of the new fund to recognize and support them. The demand thatthey be granted social and financial recognition by way of the Act on Labour Standards was notaccepted. Although we count on "natural helpers" tremendously, it is as though they did not exist.

A citizens’ forum would advisethe board of directors of theregional board on issues relat-ed to health and well-being. Itwould be composed of 15 to20 people. The memberswould be appointed by theboard of directors of theregional board, on the basis ofvarious criteria. The Forumwould be chaired by the presi-dent of the council of theregional board and would orga-nize public meetings.

The citizen’s forum would in a certain way replace the regional assembly that was abolished by Bill116. It would serve as a sort of screen for the board of directors of the regional board. The FIIQ expressed a wish, before the members of the Clair commission, that other experiences, andother participation and consultation mechanisms be experimented to enable decision-makers toadjust the supply of services to the demand and to citizens’ expectations. The Citizens’ Forumresponds to the FIIQ’s demand only in part. The mode of nomination and the limited number of peoplewho could participate are highly questionable. We must not forget that regional assemblies wereelected and represented around 150 people per region.

A Quebec agency or insurancecorporation would be createdin order to renew the role ofthe MSSS. The ministry wouldkeep the political role and theagency would assume themanagerial role.

Among the benefits of the creation of this society, the Commission states that "such an approachwould facilitate the emergence of a new paradigm that would allow elected representatives to focustheir action on the major issues and their follow-up." In reality, is the Clair Commission trying todepoliticize the issue of health?

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The Federation, like other organizations, had requested that thethree budgets from the MSSS, the RAMQ and the drug insurancebe merged in order that clinical choices be more coherent and thatthere be a better distribution of medical personnel. Instead, theCommission creates a fourth budget and proposes a strict ceilingon public expenditures. Where is the logic?

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Head Office2050 de Bleury, 4e étage, Montréal (Québec) H3A 2J5 (514) 987-1141 fax: (514) 987-7273web site: www.fiiq.qc.ca

Quebec City Office 1260, bd Lebourgneuf, # 300, Québec(Québec) G2K 2G2(418) 626-2226 fax: (418) 626-2111web site: www.fiiq.qc.ca

THE FIVE FOUNDING PRINCIPLES OF THECANADIAN HEALTH-CARESYSTEM Public administration: The health-caresystem must be operated and adminis-tered on a non-profit basis by a publicbody that is accountable to the provin-cial government.Comprehensiveness: The health insur-ance plan must cover all medicallyrequired services provided by hospitalsand physicians and, where allowed, ser-vices offered by other health-care prac-titioners.Universality: Health-care services mustbe available to all admissible residentsof Canada, according to uniform termsand conditions.Portability: Residents are entitled tohealth insurance when they move toanother province, and when they travelin Canada or abroad (subject to certainconditions).Accessibility: Residents must have rea-sonable access to all insured medicaland hospital services, according to uni-form terms and conditions. Additionalcharges cannot be billed to insuredpatients for insured services. There canbe no discrimination against a personon account of her income, age, healthstatus, etc.

IN THE END, LESS MONEY FROM THE FEDERAL GOVERNMENT

This special report wasproduced with the help ofthe Health-Care, Task andOrganization of Work andNegociation sectors, andthe Communication-Information Service:Richard BeauléMarie-Andrée ComtoisDanielle Couture Murielle DufourLucie MercierMicheline Poulin

It is difficult to assert that the Clair Report takes a clear stand in favour of privatization. Nevertheless,there are a series of signs that indicate that there is indeed an opening to the private sector. The useof new terms conceals a new reality that is not yet clearly perceptible. For example, the terms "com-modities" and "consumer goods among others" are used to refer to health services. The ClairCommission thus formally rejects the fundamental right to health, upheld by the World HealthOrganization (WHO), organisation to which it refers freely in its orientations.The "new universalism", borrowed from the WHO, involves making choices and performing. To dothis, the Commission suggests the setting up of a highly credible mechanism to constantly evaluateand revise the list of insured services, new technologies and new drugs. It proposes to update theinterpretation of the Canada Health Act. If all these interventions lead to the deinsurance of services,including lodging services, the private sector would be free to supply more services and some peoplemay no longer be able to have access to these services at all. On the other hand, the Commissiondoes not encourage professionals to question aggressive therapy, for example.Finally, as additional indication of openness to privatization, there is the adoption of a framework policy on partnership between the private sector and the tertiary sector. With this policy and theQuebec-wide investment campaign, the Commission believes that it will have the power to obtain theinvestments required for the adaptation of services, "to develop bio-medical research, promote andevaluate the best forms of organization, taking charge, use of medication and support to ‘helpers’."Recently, a partnership fund to support the helpers of people suffering from Alzheimer’s disease wasset up. With a total value of one million dollars, it is the result of the joint effort of the MSSS (100 000$) and three pharmaceutical companies (3 X 300 000$). Pfizer Canada Inc., that producesARICEPT, one of the two drugs on the market in Canada that the Conseil consultatif de pharmacologierecently refused to include on the list of drugs, is one of the partners. A plan of action with regard toAlzheimer’s disease, designed for people suffering from the disease and their helpers, will soon berevealed. This is the sign of a highly significant shift in policy. These few lines is not everything there is to say either on the content of the Clair Report or on thequestion of the reform itself which seems to be under way, in spite of a difficult context. We will nodoubt have the opportunity to talk about this again.

IS PRIVATIZATION A THREAT?

FÉDÉRATION DES INFIRMIÈRES ET INFIRMIERS DU QUÉBEC

March 2001

living, the 1998 social transfersfor Canada as a whole were45% below their 1985 level and43% less than their 1994 level.According to the availableinformation, Québec was hit bynearly 30% of these cuts, or$1.8 billion.

Despite the positive resultsobtained following lastSeptember’s federal-provincialagreement, in 2005-06, eventhough the Canadian transferpayment for Québec will be$5.15 billion, it will still belower than its 1993-94 level,when it peaked at $5.57 billion.

All things considered, thefinancial situation is rosier butthe federal government has stillbetrayed its initial commit-ments to the funding of thehealth insurance program.

health, that it would be morecomfortable if the principles of public administration, comprehensiveness, universali-ty, portability and accessibilitywere integrated into the Actrespecting health services andsocial services. By making cuts in the aggre-gate envelope of Canadiantransfer payments for healthand social programs, whichcover funding of postsecondaryeducation, health insurance,hospitalization insurance andpublic assistance, it shifts theblame for health-care cuts tothe provincial governments.Thus, in 1998, the level of federal funding received by theprovinces was the same as ithad been 15 years earlier.Taking into account populationgrowth and the rising cost of

By setting up its health andsocial services system in 1971,Québec joined the CanadaHealth Insurance Plan. At thattime, the federal and provincialgovernments shared the costsof the system 50/50.Today, despite the injections offunds by the federal govern-ment in the past two years,Canada’s contribution is muchlower than the initial rate of50%. Fortunately, however, thefederal government still makesthe payment of its share condi-tional on the provinces’ compli-ance with the five principles ofthe Canada Health Act. The FIIQhas repeatedly told the Québecgovernment, on the occasionof federal-provincial negotia-tions in which Québec arguesthe importance of respect forQuébec’s jurisdiction over

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As you will recall, there werevarious conditions attachedto the decision to accept theexploratory process. Themain one was the impor-tance of preserving the iden-tity and autonomy of theFIIQ as a Federation ofnurses. This fundamentalprinciple, so dear to nurses,guided the team throughoutits work and will serve as abasis for the analysis thatwill be presented at theMarch Federal Council. In order to be sure to takeinto consideration all theconcerns of the union repre-sentatives and leaders of theorganization, the team pre-sented regular reports to theExecutive Committee and,with the help of theEducation-AnimationService, organized meetingswith all the employees of theFIIQ and with the presidentsof affiliated unions. Thesemeetings were an opportu-nity to exchange on thereactions of members con-cerning this process and togather information on the

A process involving everyone

reaction of the other labourorganizations. They werealso an opportunity formembers of the team totransmit some informationon the FTQ, and to exchangewith union representativeson the advantages of such aprocess, for the FIIQ as wellas for the FTQ.

Discussions during thesemeetings brought the FIIQteam to delve more deeplyinto certain questions withthe FTQ and to reflect morebroadly on the future of theorganization in an ever-changing world.

At the time of going topress, the team seemed tohave everything in hand todraw up an analysis that willbe delivered to delegatesnext March. You will, ofcourse, receive informationby way of your delegates atthe Federal Council; more-over, the next issue of FIIQen Action will report on thediscussions and decisionsmade regarding the issue ofaffiliation.

In hardly three months, a lot of work has beenaccomplished, stated the Executive officer in

charge of the exploratory process with the FTQ,Sylvie Boulanger, 1st Vice-President of the FIIQ.Indeed, on December 18, just a few days after

the FIIQ work team was set up, the President ofthe Federation, Jennie Skene, accompanied bymembers of this team, met representatives of

the FTQ (Quebec Federation of Labour) , includingthe President, Mr. Henri Massé. To date, five

meetings were held in order to becomeacquainted, to exchange on our structures and

activities, and to gather as much information aspossible on this labour organization, its services

and its committees.

Reminder of the mandateJune 2000First Federal Council debate following the offer presentedby the FTQ (Quebec Federation of Labour) on the possibil-ity that the FIIQ affiliate to this labour organization. At thistime, delegates reasserted their attachment to theFederation and refused to accept the exploratory processproposed, while stating that they wished to remain opento temporary alliances.

December 2000The Executive Committee placed the question on theagenda a second time. On the one hand, several delegateshad said that they wanted the debate to be taken up again;on the other, the CSN had presented an offer similar tothat of the FTQ to the FIIQ. Delegates rejected the CSN’soffer and mandated the Executive Committee to begin anexploratory process with the FTQ in view of a possiblestructural rapprochement (affiliation).

March 2001At the Federal Council, a report on the progress of thework will be presented to delegates. Delegates will beasked to vote on whether or not to pursue the exploratoryprocess with the FTQ.

June 2001If the March Federal Council votes to pursue the process,the June Convention will then have to make a decision. Asstipulated in the FIIQ Constitution and Bylaws, if the recommendation is in favour of an affiliation, a referen-dum will be held among all the nurses of the Federation.

ONE TEAM, VARIED EXPERTISE

The FIIQ team is composed of Sylvie Boulanger, 1st Vice-President, Executive officer in charge of the issue, PaulChaput coordinator, Marie-Andrée Comtois, from theHealth-Care Sector, Pierre Desnoyers from the UnionOrganizing Service and Richard Laforest, from theLabour Relations Sector. It goes without saying that thePresident, Jennie Skene, ex officio member of the workgroup, takes part in the meetings with the FTQ represen-tatives.For the FTQ, the team is composed of René Roy,Secretary General of the FTQ, Nicole Bluteau, Vice-President, Émile Vallée and André Tremblay, consultantsat FTQ headquarters, and Dominique Savoie, researchcoordinator.

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You have been Vice-President for a little overten years. Can you remindus of the main changes inthe health-care networksince you were elected?

When I was first elected tothe Executive Committee,decisions were all central-ized by the ministry ofHealth and Social Services.At the regional level, therewere the CRSSSs, whosemandate was to apply thedecisions of the ministry,while taking into account thespecificity of their region.

The Côté reform, with theadoption of Bill 120, entailedmajor transformations. TheCRSSSs were abolished andreplaced by new decision-making bodies: the regional

boards. In institutions, abody called the Council ofNurses was set up, and forthe first time, a nurse repre-sentative was given a seaton the board of directors ofhospitals. Unfortunately, thisreform coincided with thebeginning of budget cut-backs.

However, the greatestupheaval came with theRochon reform and theobjective of reaching zerodeficit at all costs. We sawthe closing of institutions,mergers, changes of voca-tion, the shift to ambulatorycare, and all of this, ofcourse, along with consider-able _ not to say enormous_ budget cuts. The obses-sion of the Bouchard gov-

ernment with reaching thezero deficit had a majorimpact. It meant, for exam-ple, that CLSCs did notreceive the funds that hadbeen promised by the gov-ernment to set up adequateservices to respond to theneeds of patients who werenow sent home earlier.

Did the transformation ofthe health-care networkhave an impact on how theFIIQ intervened at the gov-ernment level?

Yes. At the time of theCRSSSs, the Federationspoke to the Minister ofHealth or presented positionpapers in legislative hear-ings on specific bills. Withthe creation of regionalboards, the number offorums increased. Thus,each member of theExecutive Committee isresponsible for representingthe FIIQ at two or threeregional boards. This isdone, of course, in coopera-tion with the affiliatedunions of the region. Theboards are regional bodieswhere nurses are increas-ingly present and wheretheir voice must be heard.

What is your analysis of therole that nurses occupy inrelation to the role theyshould occupy?

Currently, the workload is soheavy that little time isdevoted to teaching andsupport. Nurses are sopressed that they can onlytend to what is most urgent.And yet, nurses are trainednot only for "curing" but alsofor "caring". In the presentcontext, the expertise andknowledge of nurses are farfrom being used to theirmaximum. Nurses aretrained with a holisticapproach to care for thehealth of beneficiaries. It ishigh time that nurses beallowed to play a greaterrole in the delivery of health-care in Quebec. TheFederation has beendemanding this for a longtime and at many levels. Inits report, the ClairCommission seems to pro-mote such an approach. Itis very interesting.

Sylvie Boulanger

■ 1st Vice-President since 1990

■ political officer in charge of the Health-Careand Status of Women sectors

■ graduate from Cégep de Rimouski in 1979

■ nurse at the Centre hospitalier universitairede Québec, pavillon St-François d’Assise

■ union activist since 1988, active locally onvarious issues, the first of which was the status of women

An ever-changing networkIn past years, the health-care network underwent greatupheaval. Changes introduced by the Côté et Rochonreforms among others, combined with budget cutbacks,greatly increased the workload not only of nurses, but alsoof women in general. FIIQ Actualités met Sylvie Boulanger,executive officer in charge of the Health-Care and Status ofWomen sectors, to speak about the transformations that thenetwork underwent and their consequences. Marielle Ruel, nurse

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9

Did the health-care reformhave a specific impact onwomen?It is undeniable; the health-care reform was implement-ed at the expense of women.Since adequate measureswere not set up to supportthe shift to ambulatory careand to respond to the newneeds for home care,women were called upon forsupport. They were de factodesignated as naturalhelpers. And if, in addition,you are a nurse, the pres-sure is greater on you totake care of those aroundyou. Although, with the newbudgets announced last fall,measures will be imple-mented to respond to cer-tain needs engendered bythe shift to ambulatory care,there is unfortunately stillnothing to relieve naturalhelpers.

As Executive officer, youhave had to uphold anddefend somewhat contro-versial issues, such asabortion, violence and mid-wifery. Can you speak tous about these?Since a free-choice positionwas adopted at theFounding Convention, out ofrespect for personal values,

there were not many ten-sions around the question ofabortion. The Federationdemanded that the govern-ment make abortion ser-vices available in all regionsof Quebec. Our position onabortion is far from havingcreated turmoil in our ranks;on the contrary, it receivedthe support of the vastmajority of nurses.

On the issue of midwifery,we applied the same princi-ple: women have the right tochoose with whom andwhere they want to deliver.We toured all regions ofQuebec to answer nurses’questions regarding thecoexistence of the two pro-fessions. Afterwards, theFederation presented a briefto the parliamentary com-mission on this question.Following this consultation,pilot projects were set up.Although midwives are nowallowed to practice, the bat-tle is not over! To date, therehave been few experiencesin hospital centres to enableus to explore the variousforms of cooperation thatare possible between mid-wives and nurses.

On the subject of violence,we reached a consensus

quite rapidly. Nurses wantedto have a policy and tools tocounter violence in theworkplace. At the beginning,we focused on sexual andracial harassment.Following an inquiry con-ducted in all institutions, theFederation noted that anoth-er form of violence wasmore widespread, namelypsychological and profes-sional harassment. So, weextended our work to allforms of violence.Remember that since thelast negotiations, employersnow have the obligation tooffer nurses a sound workenvironment, free of vio-lence and all forms ofharassment.

Around 92% of the members of the FIIQ arewomen. What links of solidarity did they developwith other women?

Through their struggles,nurses have proven thattheir concerns go farbeyond strictly union ques-tions. This is why the FIIQ isgreeted well by otherwomen’s groups. A repre-sentative of the FIIQ, LucieGirard, consultant for theStatus of Women Sector,

sits on the board of direc-tors of the Fédération desFemmes du Québec. TheFIIQ is also a member of thecoalition that coordinatedthe women’s march forBread and Roses, and of theRéseau québécois d’actionsur la santé des femmes.Each group brings its expe-rience, shares its analysesof various problems experi-enced by women, and putsforward solutions that trulyrespond to their needs.These discussions helped,among other things, toestablish the demands ofthe World March of Women.Exchanging, sharing anddeveloping alliances withwomen’s groups can only bebeneficial for all women.

In past years, all nurses have had to

face, to variousdegrees, many

changes in their dailylives, as professionals,workers and women.We must continue to

move forwardtogether, side by side,to face the challenges

of the future.

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Internship inMexico

An importanteye-opener

A group of fourteenQuebec union

activists, two ofwhom were from the

FIIQ, flew off toMexico on July 2 last,to take part in a two-

week solidarity pro-gramme on the

effects of globaliza-tion. This internship

programme wasorganized by the

Centre international desolidarité ouvrière

(CISO) with itsMexican partners, the

Frente Autentico delTrabajo (FAT) and a

foundation devotedto the education of

urban and ruralworkers (RORAC).

The diversity of activitiesproposed during this intern-ship: conferences, lectures,meetings with unionactivists and strikers, as wellas visits of plants gave theparticipants a better under-standing of the political,economic and union contextof the country. The reality isquite different from theimage conveyed by theCanadian and Americanmedia. The latter speak onlyof the economic boom ofthe past years of which onlythe more wealthy feel theeffects. They rarely speak ofunemployment, corruption,violence, illiteracy andhealth problems that are thedaily lot of the Mexican peo-ple. It is impossible not tosee this during an internshipin this beautiful country. Our arrival coincided with anhistorical date. It was indeed

on July 2 that 100 millionMexicans chose to put anend to the rule of theInstitutional RevolutionaryParty (PRI), which had beenin power for 71 years. Theyelected Vincente Fox and hisparty, the National ActionParty (PAN) to rule thecountry. All the labour orga-nizations we met (FAT,SNTSS, SME) rejoiced aboutthe election results. Theywere delighted not so muchby the victory of the PAN, as by the perspective ofchange. We perceived truepride at having carried outsuch major political changewithout violence, in a demo-cratic way, like other bignations. Nevertheless, ourMexican friends said theywere sceptical that therewould be much improve-ment socially with the com-ing to power of the PAN.Indeed, the PAN, like thePRI, is a right-wing party,driven by the same values,and with the same leaningstowards the economy andforeign investments.

Work, butwhat work!One of the most intensemoments during the pro-gramme, was during theinterns’ stay in the frontiertown of Juarez. In this townlocated in the middle of theMexican desert, under ablazing sun and a tem-perature of 42o, wewent to a zone ofmaquiladoras. Inthe city of Juarez,there are over 370that employ around220 000 workers. Amaquiladora can bedefined as an indus-trial area, with clearboundaries where foreign ornational companies producegoods mainly for exporta-

tion, and to do sothey benefit fromtax breaks andother financialincentives. In otherwords, maquiladoras area paradise for employers,but quite the contrary forworkers. A few young boys, waitingfor their work team, agreedto speak to members of ourgroup. Salvatore, 18 yearsold, has been working fortwo years in a factory thatmanufactures car belts. Heearns the equivalent of 50CAN$ per week, for 45hours of work. Another boycame from Veracruz, with allhis family. All the membersof the family work inmaquiladoras and all dreamof going North.The working conditions inmaquiladoras are dreadful:high pace of work, repetitivegestures, few or no breaks,women laid off when preg-nant, no health and safetymeasures, reprisals whenworkers hold meetings anddismissal of all workers whoattempt to organize.To help workers inmaquiladoras to organize,the FAT set up the CETLACdesigned to offer, amongother things, communityeducation on subjects related to work and humanrights.

To close our visit in Juarez,we met Madam EstherChaves, founding patron ofthe Casa Amiga. This centrewas created to put an end tothe problem of violence inCiudad. No less than 215young women were mur-dered in the past years and,this is all the more alarmingsince police authorities havedone very little to try to findthe perpetrators of theseodious murders. Juarez is aviolent city where drugs,alcohol, unemployment,promiscuity and police iner-tia cohabitate: these are allelements on which violencethrives. In this context, theCasa Amiga does extraordi-nary work with women andfamilies that are victims ofthis violence.A 15-day internship is veryshort to understand all theaspects of Mexican reality,but it is enough to ensurethat we will never againthink of Mexico only as acountry of endless oceanbeaches, where the sunshines for all.

Lucille Auger, consultant Education-Animation ServiceFrançoise Gloutnay, nurse

10

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nurses, doctors, teachers,school principals and direc-tors of health institutions. Overall, our contacts withpeople were warm.However, it took a lot ofinsistence before certainhealth-care workers andpeasants agreed to meet us.Like a good number ofHaitians, they fear reprisals.And reprisals are indeedtaken against them. Whennurses try to unionize, thosewho are suspected of beingthe instigators are ques-tioned and kept under closewatch and their right towork is easily questioned.When peasants decide totake possession, for farmingpurposes, of the unexploitedland of rich landowners:crops are burnt, tools andequipment broken, peasantsare attacked during thenight. Together, they resistand hold tight, not onlyagainst the landowners butalso against governmentofficials. Due to the general disorga-nization of the country, hos-pitals are short of everything:short of medicine, short ofblood, short of qualified per-sonnel, short of basic equip-ment, short of money… Theshortage of teaching materialfor the training of nursing isa question of great concernfor the Director of Nursing atCap-Haïtien. In this respect,it is not clear that the nursingtextbooks, sent by the SINEQin spring 1999 for the train-ing of nursing students, wereever distributed. The situation in all fields andin all regions of the countryremains extremely precari-ous. Considering the politi-cal context, nothing indi-cates that the situation willimprove in the short term,even though Haitian groupsshow courage and determi-nation in their struggle toset up a true democracy, anessential premise for theimprovement of living con-ditions.

The Haitianpeople carry

on the struggle

The CISO-Haiti 2000internship pro-

gramme took placelast May. Three of the

nine participantswere from the FIIQ:

two nurses, one fromRimouski, the other

from Montreal, and aconsultant form the

Education-AnimationService. The other

members of thegroup came from

other groups belong-ing to CISO.

In order to give an accurateand global picture of the sit-uation of the country and itspopulation, visits werescheduled with labour orga-nizations and associationsmainly in Port-au-Prince,the capital, but also in Cap-Haïtien and Jacmel. Oncethere, in addition to repre-sentatives of these groups,the interns met peasants,

To help Haïti to move out ofits situation of misery,everyone agrees that inter-national aid should give pri-ority to education, sinceonly education can enablethe people to truly take thesituation in hand. The SOFAclinic (Solidarité fam aiti-ennes) put this into practice.Thus, while women wait tosee the doctor, a nurse takesthe opportunity to giveinformation on various sub-jects: food, breast-feeding,birth control, family vio-lence, STDs…in short, allinformation that canimprove the living condi-

tions of women and theirfamilies. This is exemplarycommunity education andthe organizers are rightfullyvery proud of their work.

We say that the Haitian peo-ple are peaceful, patient andcourageous, that they con-tinue to hope and fightdespite all difficulties. Thisstruggle, which the Haitianpeople have to take up againeach day, is a testimony ofthe fragility of democracy.

Hélène Tanguay, consultantEducation-Animation Service Lucienne Simard, nurse

CISO internship: Haïti - GuatemalaLike each year, CISO is organizing internships with partners in the South. Here is some information concerning these.

Objectives:● to learn about the social organizations that play an important role in the

struggles waged in these countries● to build active links of solidarity in order to face the effects of globalization● to continue exchanging and building solidarity after returning to

QuebecNumber of internships: 10 Length and dates: Two weeks

Haiti: early May 2001 (date to be confirmed)Guatemala: early July 2001 (date to be con-firmed)

Cost: 800$ per person, including travel expenses,accommodation and living expenses.

To participate, you must:● obtain the application form at the CISO secretariat CISO,

9405, Sherbrooke East, Montreal (Quebec) H1L 6P3 and return it dulycompleted no later than: March 16, 2001 for Haiti

April 9, 2001 for Guatemala ● be chosen by the selection committee● participate in the training sessions before leaving and in the evaluation

session afterwards Do not hesitate to apply.

It is a highly enriching experience!

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They have been awaited for quitesome time now… Many nurses are

anxious to attend one in theirregion… Many nurses want to know

when they will be able to benefitfrom them… Indeed, the Pension

Attention information evenings are back!

These information evenings beganat the end of February and willcontinue until all regions have

been visited. There will be at leastone per region and sometimes

more. These evenings will focusmainly on the financial aspect of

retirement. We will thereforediscuss, among other things, the

RREGOP plan, the QPP, RRSPs,progressive retirement …

everything you must know inorder to retire in good financial

health.

In the coming weeks, and coming months, keep an eye

on the bulletin board… The date, time and place of

the Pension Attention eveningwill be announced.

Don’t miss this important meeting!

Head Office2050 de Bleury, 4e étage, Montréal (Québec) H3A 2J5 (514) 987-1141 fax: (514) 987-7273web site: www.fiiq.qc.ca

Quebec City Office1260, bd Lebourgneuf, # 300, Québec (Québec) G2K 2G2(418) 626-2226 fax: (418) 626-2111web site: www.fiiq.qc.ca

FÉDÉRATION DES INFIRMIÈRESET INFIRMIERS DU QUÉBEC

▼ RETURN ADDRESS

POSTE-PUBLICATION_________________Convention 1466445

Pension Attention

PENSION

FÉDÉRATION DES INFIRMIÈRES ET INFIRMIERS DU QUÉBEC

ATTENTION4th

EDITION

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