Integrating public health into local healthcare governance in quebec: challenges in combining population and organization perspectives (original) (raw)
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Politiques de …, 2009
The quest for greater efficiency in health systems encourages governments to bring together two fields of practice that have largely developed in parallel in industrialized countries: public health and healthcare. Current healthcare reform in the province of Quebec formally integrates these two fields within a common governance structure. The objective of this paper is to discuss the issues arising from the integration of public health services into the planning and delivery of local healthcare services, and its potential effect on the overall performance of the healthcare system. The authors begin by describing the characteristics of these two sectors; then, they discuss current reforms in Quebec and the impact of various transitions (epidemiological, technological and organizational) that bring the sectors into greater convergence. The paper concludes with a discussion of obstacles and potential opportunities at two levels: (a) the development of population-based planning of services within healthcare organizations, and (b) the articulation of public health and healthcare services concerns at the local level. The ongoing reform in Quebec is a unique opportunity to maximize outcomes from the resources invested in the healthcare system, based on a collective vision for improving health.This paper was originally published in French, in the journal Pratiques et organisation des soins 39(2): 113–24.
Canadian journal of public health. Revue canadienne de santé publique
In 2004, the Quebec government undertook a major reorganization of its health care system by integrating public health more formally into local governance structures. In all, 95 new organizations - Health and Social Services Centres (CSSS)--were created and given a population-based responsibility. This mandate required that CSSSs broaden their range of services by adopting a population-based plan and integrating public health into their activities. To accomplish this, they needed to link public health and health care issues more formally within a single governance structure. The aim of this article is to identify and analyze various activities undertaken by CSSS managers to fulfill their population-based responsibility. We conducted a longitudinal case study of two CSSSs (2005-2008). Our analyses are based on real-time observations of 144 meetings of decision-makers/managers and professionals at the regional and local levels, 46 interviews with managers, as well as secondary data. C...
Canadian journal of public health = Revue canadienne de santé publique
In 2004, the Quebec government undertook a major reorganization of its health care system by integrating public health more formally into local governance structures. In all, 95 new organizations - Health and Social Services Centres (CSSS)--were created and given a population-based responsibility. This mandate required that CSSSs broaden their range of services by adopting a population-based plan and integrating public health into their activities. To accomplish this, they needed to link public health and health care issues more formally within a single governance structure. The aim of this article is to identify and analyze various activities undertaken by CSSS managers to fulfill their population-based responsibility. We conducted a longitudinal case study of two CSSSs (2005-2008). Our analyses are based on real-time observations of 144 meetings of decision-makers/managers and professionals at the regional and local levels, 46 interviews with managers, as well as secondary data. C...
Promise and peril: how health system reforms impacted public health in three Canadian provinces
Canadian Journal of Public Health
Objectives Several Canadian provinces and territories have reformed their health systems by centralizing power, resources, and responsibilities. Our study explored motivating factors and perceived impacts of centralization reforms on public health systems and essential operations. Methods A multiple case study design was used to examine three Canadian provinces that have undergone, or are in the process of undergoing, health system reform. Semi-structured interviews were conducted with 58 participants within public health at strategic and operational levels, from Alberta, Ontario, and Québec. Data were analyzed using a thematic analytical approach to iteratively conceptualize and refine themes. Results Three major themes were developed to describe the context and impacts of health system centralization reforms on public health: (1) promising “value for money” and consolidating authority; (2) impacting intersectoral and community-level collaboration; and (3) deprioritizing public hea...
Reorganising health and social care in Québec: a journey towards integrating care through mergers
London journal of primary care, 2018
Two reforms (2014, 2015) characterised by the merger of public health care establishments profoundly shaped the current organisation of Quebec's healthcare system. In 2015, 22 megastructures called Integrated Health and Social Services Centres/Integrated University Health and Social Services Centres (IHSSC/IUHSSC), were created and mandated to organise care delivery to their local populations. To describe the service configuration of the 2015 healthcare system reforms, emphasising on how it shaped the organisation of primary health care (PHC) in Quebec. With the creation of IHSSCs/IUHSSCs, Quebec's healthcare system passed from three to two levels of governance, leading to a centralisation of decision-making powers. Most health services are delivered by the new organisations, while most PHC is delivered by semi-private medical practices, mainly Family Medicine Groups (FMGs). The FMG model is the preferred strategy to develop interdisciplinary team-work and inter-organization...
Institutional Change & the Parapolitics of Community Health Centres in Québec
2001
. Even before the commission report was published, its chairman, Claude Castonguay, entered politics and immediately headed the new Ministry of Social Affairs. He had the unusual privilege of implementing the comprehensive and idealistic systems he and his commissioners had conceived as government consultants. CLSCs were thus introduced in 1971 as part of a thoroughly integrated and rationalized network of health and social care establishments. A simplified organisational chart ( provides some idea of how they fit into this network. In contrast to other provinces, the entire health system is public : hospitals, CLSCs and other organizations are public establishments, each with their own boards of directors, but with mandates, budgets and oversight, the responsibility of what came to be the Ministry of Health and Social Services. The system is made up of central, regional and local institutions, with the CLSCs representing the local level. The principal uniqueness of the system lies not so much in its public nature, as in its rational integration and its intersectoral character. While there are some distinctly health establishments, such as hospitals, and some distinctly social institutions, such as Youth and Child Protection Agencies, others have a mixed mandate -in particular, long-term care facilities and, of course, CLSCs. The enormous legitimacy enjoyed by the Québec government at the time of this initial health reform accounts in large part for the tenacity of the CLSCs. Without such high public support for these sweeping reforms, it would not have been possible to enact the kind of wall-to-wall institutional transformation that eventually turned out to be difficult to dismantle, even in the face of rapid and repeated challenges over the years. Furthermore, government control over this integrated system means that policy and programming decisions generally affect the CLSC network as a whole, rather than one CLSC at a time. It is unthinkable that Québec would today undertake a vast reform of this nature, though there is no doubt that successive governments have benefited over the years from their heightened capacity to manage this integrated sociohealth system and to harness it to both political and health-related objectives. Since 1971, the life course of the CLSCs may be divided into three distinct phases, representing different external conditions and pressures and different internal dynamics. The first phase might be called the decade of experimentation. During the first 5-year period, 70 CLSCs were rapidly established, albeit in great confusion. There was a lack of clarity of with respect to their mandate and internal organisation, with strong divisions between social groups -in particular, between local community activists and ideological professionals -over both these issues as well as others. For, while the CLSCs were originally seen as a project that allied reform-minded politicians, professionals and community groups, this was a fragile alliance with many potential areas for conflict. Furthermore, a long and contentious process of unionizing CLSC staff added to the chaos. After only 3 years of development, an evaluation was desperately commissioned by the ministry and in 1976, majority and minority reports were published, with conflicting views, of course. The minority report (Lessemann & Alary, 1975) represented a more radical view centred on local autonomy, community organization and a preventive, holistic, social approach to primary health, while the majority report preferred to see the CLSC as a more traditional, service-oriented community health centre. The majority report might have been implemented but for two events: first, outrage on the part of the new CLSCs themselves, expressed through their new Federation, for the staff did not see themselves as ordinary service providers; and second, a change of government. The new, more social democratic party in power (Parti québécois or PQ) did not implement the majority report, but neither did it endorse the minority report. Instead, it put a moratorium on the establishment of CLSCs, with the
Renewing Health Governance: A Case-Study of Newfoundland and Labrador
Canadian Political Science Review, 2009
There were several new policy reforms and discourses that intersected with the Canadian health public agenda during the 1990s. Despite new circumstances and widespread Pan-Canadian pressure and leadership calling for common health reforms, these transformations across jurisdictions or policy fields were not "inevitable" as often forecast by boosters. Our objective is to better understand the role of local contextual factors (culture, institutions, and interests) and how these have influenced provincial experiences with policy reforms. These contextual factors do not exercise similar degrees of influence upon policy change. Our goal is to explore and evaluate how health care reform evolved in Newfoundland and Labrador (NL).
This essay explores the introduction of population-needs-based funding (PNBF) formulae for the provision of health care services in five provinces (Newfoundland and Labrador, Quebec, Ontario, Saskatchewan and Alberta) as part of a larger project examining a range of health reform decisions in those provinces. Based on semi-structured key-informant interviews with civil servants, stakeholder representatives and political actors the paper examines why and how some provinces chose to move ahead with PNBF formulae while others did not. For two of the provinces (Alberta and Saskatchewan) the implementation of the formulae stemmed directly from the process of regionalization carried out shortly before, while Quebec's particular model of regionalization led to a slower and more gradual adoption of a PNBF formula. Although Newfoundland did implement a regionalized governance structure, it has not attempted to change how services have been traditionally funded, leaving much of the decision making in this area to bureaucratic and political actors. Ontario's decision to not pursue a full-scale form of regionalization meant that key stakeholders in the acute care sector could effectively block any significant discussion of changes to how health care dollars are allocated.
One step forward, one step back: Quebec's 2003-04 health and social services regionalization policy
Canadian Public Administration, 2010
This article focuses on Quebec's most recent reform in the regionalization of health care to understand why the government chose to transform the regional boards into agencies. This case study used interviews and documentary analysis. Rooted in a political science perspective, the conceptual framework is inspired by the work of John and draws on the four variables that influence the choice of policy: ideas, interests, institutions and events. Results of the case study suggest that Quebec's Commission of Study for Health and Social Services (the Clair Commission) in 2000 and the 2002 pre-electoral environment put the issue on the agenda. In 2003, the newly elected Liberal government passed Bill 25 -An Act Respecting Local Health and Social Services Network Development Agencies, which represented a political compromise: originally slated for eradication, the regional tier survived but in a new form. The element that sparked reform was the change in government following the elections. Different inquiry reports spread the reform's ideas, while interest groups articulated contrasting visions on the transformation. Above all, regional institutions showed great resilience in the face of change. From a historical perspective, this regionalization policy is a step backward: the regional tier is now stronger from a managerial and technocratic point of view, but it is politically Elisabeth Martin is a doctoral candidate,