During the past decade, the governments of Manitoba and Saskatchewan, like those in other provinces, have introduced major changes to the health care system. This process of health care reform and restructuring has been driven, in part, by federal and provincial policies to limit the role of the state and control public expenditures on health care. Health care reform has also taken place within the context of a public discourse on the determinants of health, which recognizes that health is influenced by social, economic, and environmental conditions, not simply by the delivery of health care services.

Several of the reforms in the health care system can be understood as a renegotiation of the boundaries between public and private responsibility for health. The privatization of health care refers to several different policy directions which limit the role of the public sector and define health care as a private responsibility. The privatization of health care includes:

• privatizing the costs of health care by shifting the burden of payment to individuals
• privatizing the delivery of health services by expanding opportunities for private, for-profit health service providers
• privatizing the delivery of health care services by shifting care from public institutions to community-based organizations and private households
• privatizing carework from public sector health care workers to unpaid caregivers
• privatizing management practices within the health system, by adopting the management strategies of private sector businesses.

Historically, prairie women's organizations played an important role in the development of a publicly-funded, publicly-administered health care system in Canada. Women, to a greater extent than men, utilize the health care system to access services for themselves and other family members. Women are the majority of workers in several health care occupations, and women provide most of the unpaid, informal health care within the home. Women earn less than men, are more likely to live in poverty, and are less likely to have private health insurance.

Privatization in the health care system can be expected to have significant impacts on women as users of health services, as health care workers, as informal caregivers, and as citizens engaged in public debates over the future of the health system. Women in varying circumstances, with access to different resources, will be affected by these changes in different ways.

The purpose of this paper is to provide an overview of some of the forms of health care privatization which have taken place in Manitoba and Saskatchewan in recent years, and to begin to identify some of the impacts of those changes on various groups of women.

The vast majority of health services and programs in Manitoba and Saskatchewan are provided as publicly-insured services, without additional fees charged to patients. However, many people pay privately for prescription drugs, dental care, optometric services, complementary medicines, treatments by non-physicians, long-term care, and some home care services. Since 1990, public expenditures as a proportion of total health spending have declined and private health expenditures have risen substantially. There have been significant changes to provincial prescription drug plans and the provincial public health insurance plans have de-listed or excluded several important health services. The shift from institutional to community-based care has also resulted in a transfer of costs to the individual, as services, provided at public expense to hospitalized patients, are no longer covered for outpatients. Private health insurance programs have expanded to fill the gaps in public coverage, but private insurance is not accessible to all.

In addition to the costs of health services, the delivery of health services has been privatized in a number of ways, although the patterns vary somewhat in the two provinces. Examples of privatization include the elimination of the publicly delivered school-based dental programs, the contracting out of food and cleaning services in hospitals to private, for-profit companies, the use of private, for-profit medical laboratories, the expansion of private personal care homes, the privatization of home care services, and the expansion of private heath clinics. These forms of privatization have, at times, been encouraged by government policy and, at times, been subjected to government regulation.

Health care in Manitoba and Saskatchewan has also been privatized in the sense that carework has been transferred from institutions to private households. Home care services have increased and now include a greater proportion of acute care patients. The number of institutional beds in both hospitals and nursing homes has declined. The average length of hospital stays has also been reduced.

There have been very few studies of the impacts of these changes on women, despite the fact that women are the majority of those who provide bedside care, either as paid health care workers, or unpaid informal caregivers. Among the studies surveyed, several important impacts on female health care workers were identified: loss of secure, well-paid, public sector jobs, increased workloads, stress, physical and emotional strain, financial losses, social isolation, loss of control, and working conditions which make it difficult to provide quality care.

The reorganization of heath services and the transfer of heath care costs to the individual may have affected women's access to services and the quality of care they receive, yet very little is known about the impacts of privatization on women as users of health services.

The shift from institutional to community and home care has created new demands on informal caregivers. The studies which centralize the experiences of caregivers point to the need to develop policies which will promote the well-being of care providers and enable them to deliver a high quality of care.

The impact of health care reform on women has not received the attention it deserves from the research community, although some women have been voicing their concerns about the adverse effects these changes have had on their lives and their health. This situation points to the need for a more thorough assessment of the impacts of health care privatization and other aspects of health care reform on women.

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