The cracks are still small in Canada's vaunted public health insurance system, but several of its largest provinces are beginning to open the way for private health care eventually to take root around the country.

Last week Quebec proposed to lift a ban on private health insurance for several elective surgical procedures, and announced that it would pay for such surgeries at private clinics when waiting times at public facilities were unreasonable.

The proposal, by Premier Jean Charest, who called for "a new era for health care in Quebec," came in response to a Supreme Court decision last June that struck down a provincial law that banned private medical insurance and ordered the province to initiate a reform program within a year.

The Supreme Court decision ruled that long waits for various medical procedures in the province had violated patients' "life and personal security, inviolability and freedom," and that prohibition of private health insurance was unconstitutional when the public health system did not deliver "reasonable services."

The decision applied directly only to Quebec, but it has generated movement for private clinics and private insurance in several provinces where governments hope to forestall similar court decisions.

Coincidentally, last week Premier Gordon Campbell of British Columbia asked in his Throne speech, the equivalent of a state of the province address, "Does it really matter to patients where or how they obtain their surgical treatment if it is paid for with public funds?"

It was a question that was almost unthinkable for a major politician to ask before last year's Supreme Court decision. Public health care insurance, where citizens go to their doctor or to the hospital for basic services paid for by taxpayers, has long been considered politically sacrosanct in Canada, and even central to the national identity.

Mr. Campbell presented his vision for a new provincial health care system that would resemble those of most of Western Europe, where the government pays for essential treatment delivered in both public and private clinics and hospitals.

Alberta's premier, Ralph Klein, recently expressed a similar goal, and his government is promising legislation to permit doctors to work simultaneously in private and public institutions and allow the building of private hospitals.

Quebec, Canada's second most populous province, after Ontario, has not decided to go that far. Forced by the court to meet a one-year deadline for a plan to change the system, Mr. Charest proposed limited but important changes.

He proposed that private insurance cover knee and hip replacements and cataract surgery. Publicly run hospitals would be allowed to subcontract to private clinics for such procedures when the hospitals were unable to deliver the services within six months. The plan is to be introduced in the provincial Legislature for passage before the summer.

"We're putting the private sector to work for the public," Mr. Charest told reporters. "We're taking a measured step in this direction."

Mr. Charest and the province's health minister, Philippe Couillard, called for an open debate, and they did not rule out more privatization in the future. Quebec already has about 50 private health clinics, far more than any other province, but doctors would remain forbidden to serve in both the private and public systems under the Charest plan.

Antonia Maioni, a McGill University political scientist who specializes in health care, said Mr. Charest had to be careful about pushing too hard for privatization because he knew unions and other liberals would resist sweeping changes.

"They are trying to stay politically afloat," Ms. Maioni said, noting Mr. Charest's low standing in opinion polls only a year or two before the next provincial elections. "The winds of change are blowing, but they are not knocking everything over."

Prime Minister Stephen Harper, a Conservative elected last month, did not propose a sweeping overhaul of the system in the recent national campaign. But he did favor guaranteed waiting times for services. As a free-market Conservative, he is thought to favor the Supreme Court decision and will probably try to use it to encourage changes.

The departing Liberal government opposed fundamental changes. But the new health minister, Tony Clement, is a proponent of experimentation and innovations to reduce waiting, modernize equipment and increase the supply of doctors.