Regionalization: Does It Matter? - Association of Local Public Health
Regionalization: Does It Matter? - Association of Local Public Health
Does it matter?
HEALNet Regionalization Research Centre
Centre de recherche sur la régionalisation Relais
Regionalization Research Centre
Funded by HEALNet/RELAIS (NCE)
National focus – based in Saskatoon
Study and act as a resource centre for
Work with decision makers in regional
health authorities to enhance decision
Does regionalization matter?
Overview of regionalization
Results of regionalization
Potential for public health?
Key informant survey
Issues and discussion
Problems with existing system:
Documented in late 1980s
many separate local institutions
provincial government silos
duplication and multiple entries
Focus on services and institutions
Focus on disease and treatment
Population not involved
Year of Regionalization
What is a regional health
authority (in theory)?
Autonomous health care organization with
responsibility for health administration within
a defined geographic region within a province
Has appointed or elected boards of
Is responsible for funding and delivering
community and institutional health services
within its regions.
# of regional health authorities
Note: Comparability not strict
Features: Authority & Structure
Regional, subprovincial boards (+)
Devolution of authority from province
Centralization and amalgamation of
Affiliation agreements with independent
Transfer of provincial programs
Features: Services & Programs
Single authority responsible for wider range
Attention to serving people in a more
Acute care; long-term care; public health;
community health; mental health
Avoiding duplication and multiple entries
More follow up and information
Toward community-based programs
Breadth of Scope by Province
(hospitals and/or nursing homes)
(above, plus services such as home care,
public health and addiction services)
Health and social services
(above, plus community support services
and social assistance)
(above, plus public housing and welfare
Source: Lomas, 1999
Relationship to Population health
Within/for a specific geographic region
Focus on health status as outcome
Attention to social and economic
Short and long term determinants
What is the appropriate, coherent region?
Collaboration with non-health agencies
Whose responsibility is it?
Problem of authority
Provincial government speaks “for” RHAs
Targeting of funds by the provincial
government; ad hoc interventions
Reactive deficit solving
Creation of perverse incentives
“Health boards are legally responsible for things over
which they have insufficient control.”
Who is more vulnerable to public
Province or RHAs?
Is political interference a fact of life?
Should devolution be complete?
Getting closer to “the people”
Boards as authorities
Saskatchewan and Quebec board members
Elsewhere, board members are appointed
Issues of representation and
Quality vs quantity
Problem of Provider Relationships
No physicians under regional authority
Many different service agreements and
organizations had to be made coherent
Much instability and change
Providers left out of picture
Primary care still problematic
Key Informant Survey, May 2001
Van. North Shore
Summary: What do you feel are the
positive effects of regionalization?
Enhanced local relevance of services / programs and
services delivered in appropriate location
Reduced duplication / increased consolidation
Improved efficiency and coordination
Increased cross-sectoral planning
Shifted focus from specific clients to population
Accomplished without regionalization?
“Theoretically, we could have accomplished in other ways, but I
don’t know how.”
“Although in theory it should be possible in other ways, it wasn’t
“Guess you could have accomplished this without RHAs, but it
would be difficult.”
“Possible, but difficult. Needed to break down the territoriality and
this did it.”
“Can only go so far through collaboration and horizontal integration
(e.g., through one service or one hospital integrating within).
You need one governance structure to force it to a higher level.”
“With the province in charge and funding services, focus remains
on individuals. Cannot focus on the health of a region when you
are looking at the provincial level.”
improved the services to population;
improved the integration and coordination of
the services; and
shifted the focus from specific clients to
E.g. Mental health services
Now front-line and specialists work together:
Instead of clients going directly to specialists or
hospitals for care, now go to primary care worker
who refers, case managers, etc.
Family physicians now (with the support of
specialists), provide the front line care.
Approach seems to be working
Some specialists did not like change and left.
Now looking at doing this with other groups such
as youth and elderly.
Public Health Department was separate before, but
now it is integrated into the RHA.
Director of Public Health is on management team.
Whenever we develop new models or programs, health
promotion is integrated right from the start.
But RHA does not always have the money to cover
We had an objective to increase funding by 20% for
promotion and prevention, and we didn’t achieve it.
But it’s there as a priority area, and as soon as there is
money, it will address the priorities.
From patient perspective, more
continuity of care and
More awareness throughout the system
of the various parts.
More inclusive and holistic now
But still missing doctors.
E.g. Public Health
Used to be island:
reported to municipal government
now under health board.
Over time, more joint programs :
Influenza - in past, public health would just
offer immunizations, now, they feed the
numbers back to the acute care sector to
help them plan for outbreak
Taken on physical activity as SDH corporate
New $ to Community Development
not just one sub step in a strategic goal, or an
issue relegated to a sector
SDH promotes via media and ads, work with pilot
schools to id activities, get kids involved, and work
with special or at-risk groups.
(hired 3 FTE CD workers)
No new money to public health, but they
have not had cuts, as most other areas
Vancouver North Shore:
Integration of services and continuity of
Reduced duplication in admin and mgt
Fewer management positions
Community consultations very positive
Increased awareness of Public Health
Now people from the Health promotion
sector at the management table.
Public health more integrated with
other parts. No longer a stand alone.
Always more to do, but we’ve started. Too
early to say definitively.
break down barriers between sectors,
services, and programs
Facility staff know about community services and
reconfigure services so to address client
needs not just service needs
shift funds to where needed
although acute continues to gobble
Plan together across continuum to address
E.g. concern in acute care re admissions for
asthma - traced to air quality issues. Work
with industry to try and influence their
policies on open burning, etc.
Public health has an increased accountability
no longer just accountable to prov govt
Allowed for much more planning and a planned
approach to services within a local area.
Look at the larger jurisdiction and then streamline it for the
People planning are from the local area and therefore it is
more informed planning.
People feel more a part of the system when it is local, and
they see how it all fits together.
There is a greater chance to educate the public.
E.g. co-location and multi-disc.
Community services are co-located with
multiple disciplines and
Regional services are provided by
Public health has fared very well. Seen as
critical piece of health system.
Public health folks now work with others as
part of the team.
Because of team work, people now start to
think prevention and promotion
e.g., with FAS, doctor decided and steered a
preventive focus. Integrated approach to care
helped with this.
eliminating duplication of services and
infrastructure, reducing multiple
directors and managers and services
enhancing standard practices and
systems (e.g., I.T.)
Note: Region is new
“See different people around the table and it
is easier to work across lines. The lines
between departments and sectors are
starting to meld.”
“Attending meeting tonight that involves
public health, acute care, dept of health, etc,
whereas before, we worked more in silos and
wouldn’t think so much about players or
Does RHA define its own health goals or
use provincial goals?
Typically set their own goals with some
consideration of provincial goals
How do you measure the health impacts or
outcomes of your programs?
but few evaluate health outcomes
seem to be still heavily focused on process
and interim outcomes
although they all seem to aspire in the
direction of assessing health outcomes
Saskatoon and Vancouver using Balanced
Where are we at?
Integrated, more coherent services?
Wider range of services and programs?
More client focus?
Health outcomes for evaluation?
More population participation?
Clarity and commitment about authority
Systematic outcomes evaluation
Funding matched to goals
Predictable funding and stability in the
Organized primary care
What is the appropriate division of authority?
What is the trade-off between institutional
integrity and integration of services?
More clarity about what a region is?
What is essence of a region?
Different strategies for rural and urban regions?
What is the relationship between
regionalization and “social capital”?