In the context of increasingly privatized health care within a public health care system and alongside policy scripts fueling "tax cuts," who is accountable and responsible for public health in Canada? Has "contracting out" selected types of health care really been more economically sound (cost effective) in all cases? What are the frameworks driving the debate around health spending in Canada? Is any of it even informed by evidence-based data?

Three distinguished speakers opened year's second semi-annual Canadian Conference on National Health Law entitled "Visions," by the University of Alberta's Health and Law Institute, from November 8-10 at scenic Banff in Calgary, Canada.

The Conference covers a wide range of topics on the Canadian health care system but also brings to focus many common themes and issues that very much reflect current concerns elsewhere around the world.

All three speakers presented a critique of the Chaouli v. Quebec case, which was decided by the Canadian Supreme Court in 2005, which laid the basis for opening up private insurance provided health care purchased with public money beginning 2006.

The Chaouli case involved a 73-year-old patient who had been on a "wait list" for hip surgery for some time. Together with a private doctor, Chaouli, they challenged the law in Quebec (which is similar in over 90 percent of provinces in Canada) that prohibited physicians from engaging in double dipping (engaging in public and private practice at the same time).

In its decision, the Supreme Court of Canada held that the Quebec Health Insurance Act and the Hospital Insurance Act prohibiting private medical insurance in the face of long wait times violated the Quebec Charter of Human Rights and Freedoms. Yet while public money for privately provided health care is not exactly new in Canada, the Supreme Court's reasoning came under fire because it "bought in" to a line of reasoning that equated efficiency (eliminating wait lists) with privatization and publicly provided health care as the "root cause" of wait lists.

The discussion brought to light how the issue of "wait lists" in the Canadian health system has been used not only to promote a sense of panic over the public health system's supposed inefficiency but also to usher increasing privatization of health care in Canada.

Prof. Colleen Flood, Associate Professor of the University of Toronto Faculty of Law and Chair in Health Law and Policy, began by framing the issue as a problem of accountability and not necessarily a problem of rights, in the context of recent developments in Canadian health law and policy.

According to Prof. Flood, the Supreme Court's decision was anchored on its simplistic comparison of health care systems (which in themselves are complex). Likewise, the contentious "World Health Organization" comparison (which health care advocates have raised issues with) ranked Canada's Health system as thirtieth (France was no. 1), was also cited.

Presenting empirical evidence which in fact demonstrated how Canada's maternal mortality rate and infant mortality rates are much lower than those given higher rankings in the WHO comparison, she called attention to illogic of the Supreme Court's reasoning of blaming publicly funded health care for "wait lists," and the purported promise of privatization as the panacea of "economic efficiency."

Prof. Marie-Claude Premont cited concrete examples of the fallacy of such economic efficiency and cost effectiveness arguments. She shared the case of Quebec's decision to contract out cataract removal services, which following the logic of privatization, would end up costing less and eliminate the wait lists. From a cost of C$150 in the public health system, costs jumped up to over C$300.

Prof. Flood explained this phenomenon within "privatization of health care" as partly due to the transformation of needs that occurs. Citing examples in the US scenario where otherwise unnecessary medical procedures have been marketed as "needs," the third speaker Prof. Robert Evans also noted how the issue of frameworks "public" and "private" in the health system are also profoundly ethical issues in health provision.

Interestingly, Prof. Premont's discussion of how the term "integrated health system" — which initially was intended to present the ideal of a fully integrated network of health care delivery in Quebec — has been appropriated instead to mean increasing public sponsorship and spending on private health delivery.

In the Philippines, the much hyped "health reform agenda" has also been under scrutiny by feminists for this same reason. Under the purported "reform," the national government has gotten away with not budgeting a single centavo on Family Planning, pointing instead to local governments, some of whom have taken the policy to mean that it is "optional" in the scheme of health care.

Indeed, even as Canada's health system, from where we stand in a country like the Philippines, is every bit enviable and ideal, these discussions have demonstrated how even emerging discourse around "public health care" is now dominated by increasingly privatization and market based "solutions" touted as the cure all for inefficiency.

In Canada, the irony is, evidence shows that despite tax cuts, health spending has not increased substantially. Likewise, wait lists (which was the bandwagon of choice to rationalize increasing privatization), still exist. In fact, the most successful models of having addressed wait lists have come from profession-led initiatives such as the "hip replacement" services set up by doctors in Ontario, targeting such wait lists.

In the end, health advocates need to look closely at implications of health policy especially in the face of states opening up to "free market" solutions as a panacea. Such shifts not only have financial implications (where money and resources are sourced) but ultimately include issues of equity and ethics in the health professions as well as the entire health system.