Backward Steps in Equity: Health System Reform's Impact on Women and Racial Minorities in Ontario.

Abstract

Every Canadian province is presently engaged in health system reform and restructuring which are justified publicly by governments as a "neutral" response to fiscal restraint and the need for greater cost-effectiveness and accountability in health service delivery. Using the case study of Ontario, Canada's largest and most ethno-racially diverse province, this paper argues that health system reform is taking place in an equity legislation vacuum. In addition, leaving equity to market forces not only places the brunt of health restructuring on women and particularly racial minority women, but also potentially undermines the stated health aims of health reform to achieve a more accountable, efficient and cost-effective system. Reforms may instead produce the opposite result, both through the loss of jobs and occupational status for women and racial and ethnic minorities, and through the decreased ability of health facilities to meet the needs of their diverse communities. Although employment equity is often cast in terms of individual advantages, this discussion argues that there are broader benefits to the health system in maintaining the ability of health facilities to reflect and respond to an increasingly diverse public.

Introduction

Every Canadian province is presently engaged in massive health system reform involving hospital closures, mergers or downsizing, and the increasing shift of health services from hospitals to non-institutional care. Such changes reflect a radical shift in how health services are defined, funded and delivered, and are justified publicly by governments as a "neutral" response to fiscal restraint and the need for greater cost-effectiveness and accountability in service delivery. However, they have a dramatic impact on the people who work in the health system--health care is labor intensive--and on the nature of health services delivery. Women who constitute the bulk of health care workers are now bearing the brunt of hospital layoffs and there is growing anecdotal evidence that hospital downsizing is disproportionately and negatively affecting racial minority women.

If there was ever a role for equity legislation, it is in the health area. Equity in the health system should be a key concern given the massive changes currently occurring in the health sector, the importance of health care as a primary social service for federal and provincial governments, the stated aim of medicare to guarantee Canadians equitable access to care, and the increasing sensitivity to the health services of ethno-racially diverse communities applied by successive governments and health policy-makers. Instead there is a virtual equity legislation vacuum.

This paper uses as a case study Ontario, Canada's largest and most ethno-racially diverse province. According to the 1996 Statistics Canada census data, more than half of the total population of Canada's 1.7 million visible minorities live in this province, with the large majority 1.3 million) living in Toronto, Canada's largest city. In 1995, the current Conservative government in Ontario pushed equity issues off the public agenda with the Job Quotas Repeal Act which also cancelled the provisions in the Ontario Human Rights Code, the Police Services Act, and the Education Act that related to employment equity. At the same time, it established in April 1996 an independent Health Services Restructuring Commission with the power to make radical changes to the province's health system including ordering the amalgamation and closing of hospitals.

This paper argues that leaving equity to market forces not only places the brunt of health restructuring on women and particularly racial minority women, but also potentially undermines the stated health aims of the present health reform in Ontario; namely, to achieve a more accountable, efficient and cost-effective system. Instead reforms may produce the opposite result, both through the loss of jobs and occupational status for racial and ethnic minority women and through the decreased ability of health facilities to reflect and respond to the needs of their diverse communities. While employment equity is often seen as enhancing the opportunities of disadvantaged individuals, this discussion argues that there are important economic and social benefits to the health system that emanate from its ability to reflect and respond to an increasingly diverse public.

Setting Back the Clock on Equity in Ontario

In Canada, as in the United States, there is an overarching legislative framework prohibiting discrimination on a number of grounds including race, sex, religion, and disability. For Canada, this is established by the Charter of Rights and Freedoms embedded in the Constitution and the Canadian Human Rights Act. Employment equity is seen to be a more proactive approach that not

only forbids discrimination, but also permits the implementation of special accommodation and positive measures to help "level" the playing field for historically disadvantaged groups. Employment equity legislation has been in place at the federal level since 1986 and was revised and strengthened in 1996 (Lum 1995, 1998). Because of the constitutional division of powers in Canada, this legislation applies only to the federal level covering approximately 8% of the work force who are employed in the federal public sector or in federally regulated organizations (Statutes of Canada 1996). Furthermore, there is no requirement for provinces to generate comparable employment equity legislation and structures.

Nevertheless, in September 1994, Ontario under the New Democratic Party became the first province to enact Canada's toughest equity legislation because, in its view, …