The Restructuring of the Health Care System in Quebec: Its Impact

The Restructuring of the
Health Care System in
Quebec: Its Impact on
the Women's Health
Movement
JACINTHE MICHAUD
ntroduction
In 1992, the government of Quebec created 17
regional health boards, thus acting on one of the major recommendations of the Rochon Commission that had looked at
the provincial health care system.' As a result of this reorganization of health and social services, decisions would be made differently as new political actors would supervise, at the regional level,
the budget and the distribution of resources. Community organizations, among them women's groups, would have some of their
services officially recognized and, therefore, would count among
the political actors represented within the newly created regional
boards. This led to debates within the women's groups about the
best strategies for their relations with the state.
It was not the first time in recent history that women's groups
had found themselves engaged in fierce internal debates about
their participation in state structures. These debates are not simple
as each set of collective actors has within it a range of understandings of the political and ideological process of participation
itself and of the process of defining objectives, policies and guidelines for the redistribution of funding in which they are supposed
to participate. In the past, where there had been a political orientation toward non-participation
in any level of government
activity, it had largely been justified by a fear of co-optation and
concern that the group's autonomy would be weakened through
state administrative control. With time, however, the argument
suggesting that it has become impossible to avoid the state's
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Studies in Political Economy 61, Spring 2000
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influence in women's lives and its interaction with women's
groups seems to have overcome the last pockets of resistance
against participating in state structures.2 With the restructuring of
Quebec's health care system, however, new concerns surfaced
about the implications of regionalization and its impact on feminist practice. While the government has explicitly recognized the
participation of community organizations in the reform, women's
groups have pointed out that the regionalization of the health care
system and social services also has the negative effect of fragmenting feminist expertise and feminist practice. Women's grassroots organizations are worried that funding, once allocated
provincially according to one set of criteria for the whole of
Quebec, will result in an uneven allocation once the distribution is
decided regionally. They also fear that this funding may go only to
selected activities, instead of supporting the entire range of alternative and feminist expertise they have developed over the years.t
As in earlier periods, women's groups cannot avoid political
debates on the best way to transform the hegemonic or dominant
discourses that impact on women's lives," be it in the areas of
health, poverty, violence, sexuality, the body or the search for
autonomy in all aspects of women's personal lives. In the case of
the present process of restructuring, there are two discursive
terrains that have primarily shaped the process of participation.>
The first discursive terrain concerns the learning of administrative language and the understanding of the bureaucratic management model that shapes the state's ideology of participation. In a
context where new rules are set for political representation within
the health care system, women's groups seem to be left with no
choice but to learn the technocratic functioning of the bureaucratic model if they want to be effective in the decision-making
process.
The second discursive terrain is hidden by the overwhelming
practical urgency of the first but it is equally, if not more, significant. It is the terrain that encompasses the broad societal definitions of appropriate sex roles and, as with all discursive terrains, it
is a struggle over ideology and the reconstitution of hegemony. As
women's groups emerged as collective actors within a space of
political visibility, they carried with them a counter-discourse that
opposes traditional images of women. Women's groups were one
of many collective actors interested in intervening in the process
of defining a "new societal paradigm"6 that could encompass
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many perspectives on such diversified issues as family units,
parental rights, sexuality, reproductive issues of social categories
of women, income security, poverty, mental health, and so forth.
This article will focus on the experience of women's health
centres, their political visibility and their specific location within
the health care system in Quebec." The objective is to understand
the impact of the restructuring of the health care system on the
women's health movement. This will be done primarily through a
study of the women's health centres. These health centres have
always taken an ambiguous position in relation to the participation
in state structures, as can be seen from their internal political
debates throughout the eighties.f The article begins with an
account of the evolution of the relationship between the institutional network of the Ministry of Health and Social Services
(MSSS) and the feminist and alternative network of the health
centres movement. Following this, I will examine the meanings
attached to the concepts of "partnership" and "complementarity"
as they appear in state discourse and how these have shaped the
discursive terrains within which competitive collective actors,
including community organizations, are evolving.? Finally, the
article concludes with an argument on the necessity to renew
feminist counter-hegemonic discourse on women's health.
Women's Health Centres and their Location within the
Quebec Health Care System
Six health centres for women
emerged in Quebec between 1975 and 1982. The first, the
Montreal health centre, took over the abortion referral services
from two of the early women's groups-the
"Front de liberation
des femmes du Quebec" (1969-1971) and the "Centre des
femmes" (1972-1974).10 The Quebec City health centre was the
first to offer complete abortion services when it opened in 1978.
During the same year, the Sherbrookeu health centre began its
operations. In 1981, centres opened in Trois-Rivieres and in Hull,
followed by the Lanaudiere health centre in 1982.12 In 1985, these
six health centres for women officially created the "Regroupement
des Centres de sante des femmes du Quebec.U"
Women's lack of control over their bodies in the area of reproductive rights, particularly as represented by the refusal of accredited hospitals in French-speaking Quebec to do abortions.i- constituted the context and provided the pretext for the creation of the
health centres. In first operating a referral service for illegal but
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not secretive abortions, early feminist activists developed a radical critique of scientific medicine. Later, they took advantage of
the state-controlled health care system to identify other areas of
scientific medicine that completely ignored both women's
demands and their specific needs.J5
The reform which introduced the state-controlled health care
system in 1970 did not foresee the emergence of health centres for
women, nor did it intend to give any active participation to
collective actors interested in developing alternative practices.
The reformers wanted to promote the participation of citizens,
mainly at the service delivery level and in particular within CLSCs
(Local Community Health Services Centres), a new structure
implemented at the community level and designed to develop
front line and prevention services.tv In spite of this openness to
individual participation and, to some extent, to the democratization of health care structures at the local and regional levels, the
1970 reform was characterized by centralization; a centralization
that shaped the political representation for women's groups representatives with the Ministry of Health and Social Services.
The health centres for women in Quebec were unique, compared to similar clinics elsewhere in North America.!? in terms of
their capacity for networking among themselves and with other
women's organizations that have developed specific services
adapted to the needs of women within their respective communities. Furthermore, Quebec women's health centres were at the
crossroads of political and cultural influences. In addition to North
American influences on the issue of women's health, feminist
health activists were also inspired by other practices coming from
France, particularly from Aix-en-Provence, on the political necessity to practice illegal abortions within health centres controlled
by women.J8
The health centres saw themselves as agents for the ideological
and political transformation of scientific medicine and as active
participants within the health care system. Their intent to develop
self-help practices was clearly an alternative to the services provided within medical establishments meant to advance feminist
expertise and knowledge that countered the traditional views held
by the medical profession. Their feminist discourse was articulated around three fundamental principles, known as the three "Ds:"
"de-medicalization,"
"de-professionalization"
and "de-sexization."19 The three "Ds" not only represented the feminist critique
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Care
of scientific medicine but were also intended to create a site where
a complete corpus of knowledge on women's health would be
developed, where new ways of dealing with women's bodies
would be practised, where new alternative and feminist services
would be created based on a collective approach of learning and
sharing, and where hierarchical structures would be replaced by a
principle of equality among all women. Finally, health centres
wanted to look at women's health holistically. In doing so, they
developed and maintained close ties with their communities.
Within this context, the formation of a feminist counter-discourse
within health centres was constantly confronted with the challenge
of integrating the social and economic factors that impact on
women's lives, and that are continually active on the periphery of
the traditional definition of health. For instance, issues of sexual
orientation and class constantly questioned the core of feminist
discourse on sexuality, abortion and control over the body,
although from the margins of the core feminist health platform.e?
Although they located their practice outside the medical establishment because of its alternative and feminist nature, health
centres for women were rapidly confronted with the necessity of
positioning themselves at different levels of the system. The reality of their daily practices and the nature of the services they
delivered required ongoing and intricate contact with the local
medical establishments, either through lobbying for acceptance-!
or for access to medical services and laboratory testing.
A review of the early stages in the creation of health centres
allows us to locate the origin of the relationship between the institutional network of health services and the alternative and feminist
network. In the early years, feminist health activists came from
diverse milieus and many were already working within medical
institutions. They were nurses, social workers, and sometimes
doctors. Their location within the institutional network of the
health care system meant that they knew the system and were
aware of its deficiencies towards women. At the same time they
were contributing, with other feminist activists, to the development of a feminist critique of scientific medicine and its traditional representation of women's bodies and to the formation of a new
feminist knowledge and expertise.F
This knowledge was circulating with two different models of
intervention, one with the institutional network and another with the
feminist and alternative network. In the case of the institutional
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network, the circulation of knowledge took the form of slow but
at least partial infiltration of the experience of the women's health
centres into the traditional structures. The collective approach
favoured by health centres was to some extent adopted by some
CLSCs, which for example, organized workshops on specific
women's health issues. However, in doing so, they were subject to
the criticism of many feminist health activists that medical establishments were not necessarily recognizing the feminist discourse
and expertise so patiently developed by health centres for women.
What medical establishments had done, they argued, was to co-opt
parts of the women's health centres' approach in order to respond
to women's growing demand for change.
Despite these criticisms, feminist health activists did bring their
expertise to bear at numerous levels of the institutional network,
mainly through CLSCs and some hospitals. Their objectives were
to change traditional medical practices towards women, to attempt
to incorporate feminist expertise wherever possible, and to present
themselves as the only alternative capable of adequately responding to women's specific needs.
The impact of these efforts of alternative and feminist health
professionals to influence the traditional networks remains difficult to measure. This was not, however, the only route followed.
From the moment women's health centres began to promote the
quality of their services and their feminist expertise, and bolstered
by the growing demands from the women in the communities in
which they operated, they started to look for official recognition.
And, of course, the measure of this recognition was adequate
government funding.e'
Evolution of the Practice of Participation The previous discussion allows us to see the interrelations between the two discursive
terrains within which women's health centres had to articulate
their claims. In the beginning, the creation of a feminist counterdiscourse channelled a good deal of the energies of the feminist
health activists. At the same time, however, relationships were
being developed between the institutional network of health and
social services and the feminist and alternative network and this
led to the need to adapt their discourse to the established bureaucratic model.
The feminist health activists started to develop with the
Ministry of Health and Social Services (MSSS) an argument about
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Care
their central place in any discussion of women's health issues
because of the quality of their services and of their feminist and
alternative expertise. The bureaucratic and administrative relationship between the state and women's groups evolved considerably throughout the eighties until the establishment of regional
boards by the MSSS in 1992. For example, by the mid 1980s, the
Quebec government had clearly stated in its "plan of action" that
women's groups should be recognized as "partners" in the implementation of policies and social programs for women across the
public sector.s- From that moment, as we will see in the following
section, the concept of "partnership" begins to take on real meaning in the minds of feminist and community activists.
Before 1992, women's service groups,25 including health
centres for women, prepared and presented their funding requests
directly to the minister's office every year. Through this process,
representatives of women's groups were able to meet with political
actors and sometimes with the minister him/herself. This gave
women's groups an opportunity, which they took full advantage of,
to emphasize the importance of their services to their communities.
With the 1992 reform and the creation of the regional health
boards, the centralized nature of the system and the process of representation changed significantly. The reasons for the regionalization stem from the thinking of the Rochon Commission.
According to one analysis, the Rochon Commission found that the
system was good and overall public satisfaction very high, but that
there was "[N]ot enough decentalization (sic) and not enough citizen participation since the system has become the hostage of
countless interest groupS."26 The Commission felt that the interests of citizens are in opposition to those of "groups of producers,
groups of institutions, groups of community-based
activists,
unions and so forth,"27 that:
[m]ake it difficult for the system to adjust to the changing needs of the
population, to motivate its personnel, to redistribute the powers and
functions of the various bodies to better serve the public, to foster
participation of citizens in decision making, to decentralize its
management and to consider its financing to improve the delivery of
services and the efficiency of the system.P
Based on the positive levels of public satisfaction, the
Commission could have proposed minor adjustments but, as
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Pineault notes, it chose instead to recommend:
[t]hat the system be more centred on the individuals rather than on the
providers. In particular, it recommended that regional councils be
replaced by regional bodies that would be granted the power of direct
taxation and whose members would be elected by universal ballot. In
other words, the Commission opted for a true political decentralization
rather than only an administrative one.29
The resulting legislation endorsed the Commission's recommendations to place the individual at the centre of the reform,
although it did not adopt the portion regarding taxation)O Also, the
overall changes to the system did not reflect true decentralization,
but rather a deconcentration of the decision-making process, since
the budget and priorities are still centralized at the ministry level.
However, for community organizations in general and women's
groups in particular, the changes introduced in the system are significant both in terms of the recognition of the community sector
and of the changes in the structure of political representation.
Recognition of the work and services performed within the
community sector meant that core financing would be assured,
providing groups participated in the implementation ofthe reform.
In order to understand what this requirement meant for women's
groups we need to understand more clearly the overall context of
state action. The context is what Jocelyne Lamoureux and
Frederic Lesemann have defined as being the welfare state crisis,
and which the state articulates in terms of calls for community
responsibility, solidarity among citizens, the development of volunteer work and partnership. The logical underpinning ofthis governmental approach towards a whole range of community organizations is, above all, administrative and motivated by budget
restraints.u
As for political representation, the way in which women's
groups prepared and presented their budget requests was completely modified by the reform. With the implementation of 17
regional boards, the practice of political representation took on a
more restrictive meaning for women's groups. Women's groups
were now asked to negotiate their financing through regional
boards that were in charge of distributing the overall regional budget and that had a say in the official recognition of community
organizations working at the regional level. Even though the
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community sector is recognized and the participation of community organizations required, it was not at all certain that women's
groups would gain in visibility and political influence. The new
rules of the game were much tougher for feminist activists,
whether or not they became elected representatives on the new
regional boards. The possibility of arranging meetings at the highest level ofthe MSSS was now more limited. Regional recognition
would exist but it would be uneven.
Consider the distribution of elected representatives within the
regional boards. Twenty percent of the seats are reserved for community organizations, one quarter of which are to be for women's
groups. However, there is nothing official about the number of
places to be reserved for organizations that are working on
women's issues.t- The remaining 80 percent of seats on the
regional boards were be distributed as follows: 20 percent would
be elected by municipalities; 20 percent would be "elected by the
organizations the regional board designates as being the most representative of socio-economic groups,"33 and 40 percent would be
elected from boards of directors of private and public medical
establishments.v The number of seats varies from one region to
another. For example, in the metropolitain region of Quebec City,
the regional board is composed of 120 seats, with 24 reserved for
the community sector, while in the less populated region of
Abitibi- Temiscamingue, the board has 60 seats, 12 of them for the
community sector.s>
This description allows us to see that women's groups have to
playa double strategy; within the community sector and within the
institutional network. At the first level, they have to exercise
influence within community groups-their
closest allies in this
process-to
ensure that the community representatives on the
regional boards represent their demands effectively. This is not an
easy task, since the community sector is both large and various,
made up of different organizations, with different political orientations and ideological value systems. Groups' mandates address a
broad range of specific issues, with different social categories of
people and with strategies for action that are not always in harmony with one another.
At the second level, women's service groups concerned with
the overall composition of regional boards have to mobilize their
energies to ensure the election of sympathetic health professionals
at different levels of local institutions such as hospitals and local
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CLSCs. The new regionalization eliminated a form of centralization
that had benefitted women's health centres)6 The new regional
boards worked to the advantage of only a few health centres, those
who were successful enough at convincing the regional representatives that they were relevant to the community and that they met the
government's political priorities. The problems of regional participation affected the question of the financing of the women's health
centres but they also affected the centres in terms of the fragmentation of their overall practices and expertise.
"Complementarity"
Versus "Partnership"
It remains to be
seen what the process of participation means for the parties
involved. How is the practice of participation seen from the perspective of women's groups and from the state perspective? To do
this we need to look at the relationship between two concepts used
to define the relations between the state and organizations in civil
society: "partnership" and "complementarity." Lamoureux and
Lesemann have analyzed this relationship and their conclusion is
clear: "partnership" and "complementarity," far from being on a
continuum as the state suggests, must be placed in opposition to
one another. Partnership, for instance, implies that the entire body
of feminist and alternative practices and expertise be acknowledged within the process. Complementarity, on the other hand,
funds and recognizes only selected activities. Complementarity
can be understood as a practice of state regulation, domination and
co-optation of vital forces within the community, while other
forces are pushed aside)? In her more recent work, Jocelyne
Lamoureux argues that complementarity represents a very negative element of the participation process and is something that
community organizations reject. In the practice of complementarity, services are recognized by the state only in a very partial manner; they are selected by the state without any consideration for the
global expertise and holistic approach developed within the community over time.v
It is also true that the concept of "partnership" itself can have
different meanings, depending on which constituency is using it.
In analyzing the coalition work between community-based AIDS
organizations and the federal government, Gary Kinsman argues
that community organizations view partnership as meaning "that
governments need to recognize the leadership and contribution of
community-based groups" and as "something close to an equal
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relationship between government
argues that the use of partnership
ment underlines a strategy that
organizations in "state messages
neutralization
of the relations
unequal in civil society:
Care
and agencies."39 However, he
by different levels of governinvolves different groups and
and regulation.t'-v as well as a
among groups which remain
"Partnership" has a nice neutral ring to it. It is difficult to question or
oppose because it draws us into constructing a consensus. Partnership
sounds consensual, it implies that everyone is being given an equal
voice, that all partners are equal. It is therefore a useful conceptualization for the construction of hegemonic relations.t!
If partnership sometimes carries an ambiguous message, complementarity is clearly negative. We saw earlier that the Quebec
government had used the word "partners" in its "plan of action,"
in the mid 1980s when referring to the relationship it wanted to
establish with women's groups. However, the government's position changed shortly after this initial formation as, for example, in
the violence against women policy.s? where the concept of partnership was replaced by complementarity. The provincial network
of shelters specifically criticized this position, arguing that it represented the co-optation of services within governmental administrative structures. This provincial network opposes funding for
"Bed & Breakfast" services only, while the shelters' overall expertise and practice in the area of violence against women is ignored.
It is not surprising, therefore, that the same provincial network,
although agreeing with the overall process of participation, continues to oppose the co-optation inherent in complementarity.O
Not surprisingly, the Rochon Commission, which strongly
recommended the official recognition and the financing of community organizations by the Ministry of Health and Social
Services.s- is almost totally silent on the subject of partnerships in
the way that community organizations understand them. The
health policy adopted in 1992 entrenched the concept of complementarity.s> The regionalization of the system and the establishment of priorities and targetted social categories institutionalizes
this complementarity that has been so criticized by community
organizations. It is clear, for instance, that complementarity with
medical establishments will increase the inequality of status not
only with those establishments but among interest groups which
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claim an expertise in this area.46 In this case, then, the danger
becomes the administrative integration of community organizations, an integration which leads to the possibility of further
marginalization, exclusion and the silencing of voices that were
once the most important critics of governmental policies and
action in civil society. The government can then use the small
number of health centres as an argument against financing them.
Their relevance is weakened further since some medical establishments, CLSCs in particular and those establishments which
have slowly integrated ways of dealing with women, are now pretending to offer the same services as women's health centres.
Thus, financing women's groups, according to the principle of
complementarity as opposed to the principle of partnership, means
that funds are allocated for "Bed & Breakfast" services, in the case
of shelters or for women's health centres performing abortions.s?
but not for education, prevention or other expertise that feminist
activists have developed holistically over the years on women's
health-related issues.
Conclusion: On the Necessity of Renewal of a Feminist CounterDiscourse The regional level, even if limited, does represent a
space for the political visibility of women's groups. Regional
boards are also a space where alliances, confrontation and compromise among new "partners" call for more political skills than simply the ability to use administrative language and understand
bureaucratic models. Despite a specific and limited mandate,
regional boards do more than simply ensure that health services are
well organized regionally, according to a fixed budget and the priorities established by the ministry. Regional boards constitute
above all a political space in which different visions of the world
and different ideological and political definitions of health interact
and evolve.
In addition to the need to learn how to negotiate, women's
groups will have to create alliances with other social forces which
are more sympathetic to their political platform. Participation,
then, structures a process among collective actors which offers
institutional recognition and enables these actors to claim a say in
the way women's health and women's representation are defined.
For some women's groups it is clear that to refuse this type of
participation and political visibility is to give a free ride to other
collective actors which do not defend alternative and feminist
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Care
models.w It is in these terms that the larger network of women's
shelters understood the reality of participation: to counteract
"familialist" ideology within the institutional network and other
"psychologist" approaches adopted by some social forces within
civil society.s? As we have seen earlier, these were also the reasons
why feminist health activists tried to engage directly with the medical establishment in order to change attitudes towards women and
transform the traditional representation of women's bodies by scientific medicine.
One can always object that such participation involves unequal
collective actors.w constantly being submitted to "complementarity" rather than real "partnership." Furthermore, the risk remains
that such restrictive institutionalization
will have a negative
impact on the counter-discourse of women's groups. However, in
addition to gaining adequate financing and institutional recognition, agreeing to play the game of participation can also allow
women's groups to maintain their primary objective of countering
and transforming undesirable discursive models. This objective
can even be considered the major reason for undertaking this political exercise, which will always carry with it a high degree offrustration. The central aspect is less the question of whether or not to
participate but rather that of recognizing that the ultimate challenge for change remains with the internal dynamic of feminist
discourse formation.
The potential of forming a powerful feminist counter-discourse
remains and will always remain with communities of women. It
was within communities of women that the feminist project on
health was born. It was from their specific needs to de-medicalize,
de-sexize and de-professionalize that health centres felt the need
to create their own space for developing alternative services, a
space where a feminist critique of scientific medicine was possible. This feminist discourse denounced women's oppression and
demanded women's autonomy in all aspects of their personal,
political, economical, social and cultural lives.
Health centres for women put into place abortion clinics and
self-help practices during a period in which the political and social
context favoured a collective approach, although with a political
consciousness formed from well-educated, white, urban, middleclass women. It was from their perspective that the first generation
of feminist health activists was able to articulate its counter-dis-
course.
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Times have changed and the ways of looking at women's reality and experiences have evolved considerably over the years.
Identities based on class, sexual orientation, race and ability have
voiced claims for visibility and for inclusion within the women's
movement. The feminist core discourse within any women's organization is questioned, challenged and sometimes transformed
qualitatively from those collective identities. The demands on
women's health services coming from class experience, sexual
orientation, race and ability, even when emerging on the margins
have the potential to transform this core discourse. Up until the
present, health centres for women have been more or less successful in adapting their feminist discourse to better integrate
diversities,» However, they can no longer afford to consider
issues of diversity as mere demands to be added to a list already
full of other considerations. Inclusion of diversity in the core feminist discourse involves a transformation that determines the ways
women's groups will look at health-related issues within all those
spaces of political visibility in which they choose to intervene.
This means that the internal dynamic of discourse formation
must be recognized in all its complexity, especially since women's
groups are engaged in several kinds of solidarity coalitions where
the process of merging interests and reconciling diverse priorities
necessitates an ongoing negotiation among all the parties
involved. 52 What becomes essential in the process of inclusion is
not only the final result in terms of content but also the process by
which discourse formation is negotiated among the participants.
With a feminist counter-discourse capable of renewal, the feminist
health movement can present itself as a legitimate and necessary
collective actor more inextricably connected to communities of
women than any other "partners" involved in the participation
process. Feminist and community activists, by remaining in close
connection to their communities, have the political means to maintain a counter-discourse aimed at transforming the hegemonic
representation of women.
Notes
I would like to thank the reviewers of Studies in Political Economy for their
thoughtful comments, especially Caroline Andrew for her helpful recommendations on the final version of this article.
1. Gouvernement du Quebec, Rapport de la Commission d'enquete sur les services de sante et les services sociaux (Quebec: Publications du Quebec, 1988).
44
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Care
2. Lamoureux, Jocelyne, Le partenariat a l'epreuve, (Montreal: Albert SaintMartin, 1994); Franzway, Suzanne, Diane Court, and R.w. Connell, Staking
a Claim: Feminism, Bureaucracy and the State, (Cambridge: Polity Press,
1989); Regroupement provincial des maisons d'hebergement et de transition
pour femmes victimes de violence conjugale, Au grand jour, Madeleine
Lacombe, (redaction) (Montreal: remue-menage, 1989).
3. Lamoureux, Le partenariat a l'epreuve; Regroupement provincial, Au grand
jour.
4. Marques-Pereira, Berangere, "L'Etat-providence, providence de l'Etat a l'egard des femmes," Recherches feministes 3/1 (1990), p. 22.
5. Michaud, Jacinthe, Angels Makers or Trouble Makers: The Health Centres
Movement
Hegemony
in Quebec and the Conditions of Formations of a Counteron Health Unpublished Ph.D. dissertation, University of Toronto
(1995).
6. Jenson, Jane "All the World's a Stage: Ideas, Space and Times in Canadian
Political Economy," Studies in Political Economy 36 (1991), p. 43-72;
"Paradigms and Political Discourse: Protective Legislation in France and the
United States Before 1914," Canadian Journal of Political Science 22/2
(1989), pp. 235-258; "Gender and Reproduction: Or, Babies and the State,"
Studies in Political Economy 20 (1986), pp. 9-46.
7. This article is based on extensive research I conducted with the Quebec
health centres movement. Most of the information gathered comes from
groups' documents and from interviews I conducted between 1991 and 1992
with feminist health activists and participants in women's groups concerned
by restructuring. Translated quotations from interviewees will appear in endnotes wherever necessary.
8. Michaud, "The Welfare State and the Problem of Counter-Hegemonic
Responses Within the Women's Movement," Angel Makers or Trouble Makers;
William K. Carroll, (ed), Organizing Dissent: Contemporary
Social
Movements in Theory and in Practice, First edition, (Garamond Press: 1992),
pp. 200-214; Relais-femmes, «I:e Regroupement des Centres de sante pour les
femmes et la non-participation» redige par Josee Belleau, Les rapports des
groupes de femmes avec I 'Etat, Compte rendu de la joumee de reflexion organisee par Relais-femmes (1985), pp. 15-20.
9. Boivin, Louise, "L'economie sociale: ou comment faire passer en douceur la
reduction des depenses sociales de l'Etat," Temps fou (1995-1996), pp.8-11;
Valois, Pierre, "Desengagement ou des engagement?," Virtualites 3/1
(novembre-decembre 1995), pp. 9-14; Lamoureux, Le partenariat
a
l'epreuve; Lamoureux, Jocelyne et Frederic Lesemann, Les filieres d'action
sociale: les rapports entre les services sociaux publics et les pratiques communautaires. Presente ilia Commission d'enquete sur les services de sante et
les services sociaux (Quebec: Publications du Quebec 1987).
10. O'Leary, Veronique and Louise Toupin, Quebecoises deboutte! 1 et 2
(Montreal: Editions du remue-menage, 1982).
11. The clinic in Sherbrooke is the only women's health centre that does not offer
abortion services.
12. The Lanaudiere health centre closed in 1986.
13. In 1992, only a few health centres (Montreal, Sherbrooke, Trois-Rivieres)
remain members of this provincial network.
14. The Comite de lutte pour l'avortement libre et gratuit revealed that on 5,657
abortions performed in 1975, 5,418 took place within anglophone hospitals.
See, Comite pour l'avortement libre et gratuit C'est a nous de decider.
(Montreal: Les editions du remue-menage, 1978), p. 21-22.
15. Ibid.
45
Studies in Political Economy
16.
17.
18.
19.
20.
21.
22.
23.
46
Gouvernement du Quebec, Rapport de la Commission, p. 210.
Morgen, Sandra, "Contradiction
in Feminist Practice: Individualism and
Collectivism in a Feminist Health Centre," Comparative Social Research: A
Research Annual, T.M.S. Evens and James L. Peacock, (volume eds.), (Jai
Press inc.: 1990), pp. 9-59; "The Dynamic of Co-optation in a Feminist
Health Clinic," Social Science and Medicine 23/2 (1986), pp. 201-210;
Thurston, Maxine Amelia, "Strategies,
Constraints
and Dilemmas
of
Alternative Organizations: A Study of Women's Health Centers," Ph.D.
Thesis (The Florida State University: School of Social Work, 1987); Saillant,
Francine, "Le mouvement pour la sante des femmes," Jacques Dufresne,
Fernand Dumont, Yves Martin, (dir.), Traite d'anthropologie medicale: l'institution de la sante et de la maladie, (Presse de I'Universite du
Quebec/Institut quebecois de recherche sur la culture/Presses universitaires
de Lyon, 1985), pp. 743-762; Simonds, Ruth, Kay, Bonnie K. and Carol
Regan, "Women's Health Groups: Alternative to the Health Care System,"
International Journal of Health Services 14/4 (1984), pp.619-634; Fee,
Elisabeth, "Women and Health Care: A comparison of Theories,". Elisabeth
Fee, (ed.), Women and Health: The Politics of Sex in Medicine, Second edition (Farmingdale: Baywood Publishing Company Inc., 1983); Rusek, Sheryl
Burt, The Womens Health Movement: Feminist Challenge to Medical
Control (Preager Publishers, 1978).
Comite de lutte, C'est a nous de decider.
Regroupement
des Centres de sante des femmes du Quebec, Cadre de
reference des Centres de sante des femmes du Quebec, (1991); Un regard de
l'interieur: bilan des Centres de sante de femmes du Quebec. Caroline Larue,
(redaction), [s.l], (1987); Les centres de sante des femmes du Quebec,
Representation ecrite presentee a la Commission d'enquete sur les services
se sante et les services sociaux, Hull (1986).
Michaud, Jacinthe, "On Counter-Hegemonic Formation Within the Women's
Movement and the Difficult Integration of Collective Identities," in William
K. Carroll, (ed.), Organizing Dissent, Contemporary Social Movements in
Theory and in Practice, Second edition, (Garamond Press, 1997), pp. 197212; "Le mouvement feministe sur la sante des femmes: forces et limites de
sa formation discursive et des conditions d'emergence du cote de I'espace
public," Dyane Adam, (dir.). Femmesfrancophones
et pluralisme en milieu
minoritaire, (Ottawa: Presses de l'universite d'Ottawa, 1996), pp. 73-88.
Thurston, Strategies, Constraints and Dilemmas; Simonds et al., Women's
Health Groups.
Exerpt from a conversation with a women involved in the Montreal health
centre for women: "Les travailleuses qui etaient dans les CLSC, c'etaient des
feministes, aussi feministes que les militantes du centres de sante. C'etait des
femmes qui ont mene des batailles terribles [...]. II y en avait qui se battaient
dans leur CLSC pour qu'il y ait des pratiques collectives aussi et elles en ont
fait d' ailleurs des pratiques collectives."
Translation: "The women working in the CLSCs, they were feminists, as
feminists as the activists in the health centres. These women fought terribles
battles [... ]. Some were fighting for collective practices within their CLSCs
and some in fact had collective practices."
According to a participant in the provincial network of health centres:
"Contrairement aux annees soixante-dix OU on considerait que Ie fmancement
de I'Etat c'est de la recuperation, en 80 c'etait on rend un service public, on
repond aux besoins des femmes et on developpe des pratiques feministes en
sante et on considere que ca vaut la peine, c'est une alternative, ca remet en
question Ie systeme medical, Ie systeme de sante, ca donne du pouvoir aux
MichaudlHealth
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
Care
femmes, et il faut que l'Etat Ie reconnaisse parce que les femmes nous
appuient. C'est un peu comme developper un reseau parallele et que I'Etat
doit Ie reconnaitre et Ie finance comme tel. C'est un peu Ie requestionnement
du role de I'Etat. Je trouve, avec Ie recul, on peut Ie voir comme de la
recuperation, mais moi je pense que c'est la realisation que Ie systeme de
sante au Quebec, comme bien d'autres systemes, n'arrive pas a repondre a
tout."
Translation: "Unlike in the 70s where we thought that the government funding meant cooptation, in the 80s, we were delivering a public service, we
were responding to women's needs and developing feminist practices, and
we thought it was valuable, it was an alternative, it calls into question the
medical system, the health care system, it empowered women, and the state
had to recognize it because women supported us. It was a bit like developing
a parallel network, and the state has to recognize it as is. I think in retrospect
that it can be seen as cooptation, but I think that it is about the realization that
the health care system in Quebec, like other systems, carmot respond to
everyone's needs."
Gouvernement du Quebec, Vers l'egalite: orientations triennales en matiere
de condition feminine 1987-1990, (Quebec: Secretariat a la condition feminine, 1987b).
The expression "women service groups" is used to designate organizations
which responded to women's specific needs. In addition to health centres for
women, they are mainly shelters for women, women's centres and women's
organizations against sexual violence.
Pineault, Raynald, "The Reform of the Quebec Health-Care
System:
Potential for Innovation?" Mathwin Davis, (ed.), Health Care: Innovation,
Impact and Challenge,
(School of Public Policy/School
of Public
Administration: Queen's University, 1992), p.75.
Ibid., p.77.
Ibid., p.77.
Ibid., p.77.
Ibid., p.79.
Lamoureux and Lesemarm, Les filieres d'action sociale, p.20
A long-time feminist activist and a representative of the government drew my
attention to the lack of official representation for women's groups within
regional boards. The figure of 5 % was mentioned during an informal interview with two government representatives from the "Soutien au services
communautaires" (SOC) at the time of my research.
Pineault, The Reform of the Quebec Health-Care System, p. 83.
Ibid., p. 83.
Gouvernment of Quebec, A Reform Centred on The Citizen: Health Social
Services Reform, (Ministry of Health and Social Services, 1990).
Exerpt from a conversation with a member of the Quebec City health centre
for women: "La regionalisation a mon avis ca a du bon et ca a du moins bon,
des choses de ce genre-la et pas juste par rapport a I'avortement, mais par
rapport a d'autres questions. Des fois c'est important que ca soit centralise
pour que ca evite cesjeux de pouvoir-la, on est pas toujours d'accord avec les
decisions mais il reste a un moment donne quand il y en a une qui est prise
et qu'elle est dans notre sens, qu'elle s'impose partout, c'est quand meme un
avantage [..]."
Translation: "Regionalization is a mixed belssing, and not just with respect to
abortion, but also to a lot of other issues. Sometimes it is important that things
be centralized in order to avoid some of the power games, we don't always
agree with the decisions, but when a decision is made that goes our way,
when it's applied broadly, it's to our benefit."
47
Studies in Political Economy
37. Lamoureux and Lesemann, Les filieres d'action sociale, p. 27.
38. Lamoureux, Le partenariat a l'epreuve, 1994, p. 65-67.
39. Kinsman, Gary, "Managing AIDS Organizing: 'Consultation,' 'Partnership,'
and the National AIDS Strategy," William K. Carroll, (ed), Organizing
Dissent: Contemporary Social Movements in Theory and in Practice
(Garamond Press, 1992), p.221.
40. Ibid., p.222.
41. Ibid., p. 223.
42. Gouvernement du Quebec, Une politique d'aide aux femmes violentees,
Quebec: Ministere de la Sante et des Services Sociaux (l987a), p.34.
43. Regroupement provincial, Au grandjour; Godbout, Jacques, Murielle Leduc
et Jean-Pierre Collin, Laface cachee du systeme, Presente a la Commission
d'enquete sur les services de sante et les services sociaux, (Quebec:
Publications du Quebec, 1987), p.77.
44. Gouvernement du Quebec, Rapport de la Commission, pp.297-316.
45. Gouvernement du Quebec, La politique de la sante du bien-etre (Ministere de
la Sante et des Services Sociaux, 1992a), p.48.
46. Excerpt from a conversation with a women invloved in women's shelters
provincial network: "Non j 'aurais pas dit partenaire,j'aurais dit obligees I'un
a I'autre, je pense que notre discussion ou I'ensemble des discussions c'est
plus ... On ne peut pas se permettre de ne pas aller sur un comite oil on parle
de quelque chose qui nous concerne, pas juste la violence mais [...j qui peut
nous concerner, on ne peut pas se permettre de ne pas y aller. Parce que
comme elle dit, il y a plusieurs discours, je pense que c' est vrai, il y a
plusieurs influences, tout Ie monde est devenu specialiste de quelque chose
qui est proche de ca... avec differentes approches, on a tendance a y aller et
on dit que ca n'a pas d'allure si on n'a pas notre place et si on ne peut pas,
qu'on voit qu'on va etre la pour rien on va partir."
Translation: "No, I wouldn't have said "partner", I would have said "obligated to one another", I think our discussions were more... you can't allow yourself not to sit on a committee where they might talk about something that concerns us, not just violence, but [...j, that might concern us, you just can't not
go. Like she said, there are several positions, I think it's true, there are several influences, everyone's become a specialist in something in this area...
there are different approaches, you go there and you say this doen't make
sense if we don't have a place here, and if we can't, if we see that we're going
to be there for nothing, we'll leave."
47. It has never been a problem for health centres for women to get refunded by
the "Regie de I'assurance maladie du Quebec" (RAMQ) when it comes to
practice abortions performed by doctors, as well as other gynecological practices. And for a long period oftime, between 1978 and 1988, health centres
were almost the only place where it was possible to have access to safe abortions.
48. Lamoureux, Jocelyne, Le partenariat a l'epreuve, p.l65; Regroupement
provincial, Au grandjour, p.104
49. Regroupement provincial, Au grandjour, pp. 119-135.
50. Boivin, L'economie sociale; Kinsman, "Managing AIDS Organizing;"
Lamoureux and Lesemann, Les filieres d'action sociale.
51. Michaud, "On Counter-Hegemonic Formation," 1997.
52. Michaud, Angel Makers or Trouble Makers; Michaud, "The Welfare State
and the Problem of Counter-Hegemonic Responses Within the Women's
Movement."
48