The Reform to Regionalization in Quebec: Towards a New Model of

Local Governance in Health Care

Elisabeth MARTIN, Ph.D candidateMarie-Pascale POMEY, M.D., Ph.D.

Pierre-Gerlier FOREST, Ph.D.

2006 National Healthcare Leadership Conference

Victoria (BC), June 12 & 13, 2006

Acknowledgments

Research project funded by the Canadian Institutes of Health Research

Research grant # 136723

Quebec research team: Laval University and University of Montreal

Presentation outline

1. Research project: objectives, theoretical framework and methodology

2. History of regionalization in Quebec (1971-2001)

3. Presentation of Bill 25

4. Governemental agenda, decision agenda, policy choice

5. Implementation

6. Conclusion: key success factors and challenges ahead

THE RESEARCH PROJECT

The research project

Results from a research project: A Cross-Provincial Comparison of Health Care Policy Reform in Canada (H. Lazar, PI)

6 case studies of policy reform undertaken in 5 provinces (AB, SK, ON, QC, NFL)

One case study on regionalization of health services

Research objectives

Describe the policy-making process Analyze the factors that explain why the

public policy-making process unfolded the way it did

To identify patterns in the distribution of these factors across policies within a province and across provinces

To derive policy implications for federal and provincial policy-makers

Theoretical framework

Theoretical framework rooted in John Kingdon’s public policy work (2002, 2nd edition):– Governemental agenda– Decision agenda– Policy choice

Variables:– Institutions– Interests– Ideas– External events

Methodology

Data gathered through 10 semi-structured interviews with key actors and decision-makers involved in the reform process

Interviews were transcribed, coded (NVivo) and analysed

Analysis of relevant literature:– Grey and scientific literature on regionalization– Governmental publications & reports

INTRODUCTION: Regionalization of health

services in Quebec

3 key moments in the history of regionalization in Quebec

1971- 12 Health and Social Services Regional Councils

1991- 18 Health and Social Services Regional Boards

2003- Adoption of Bill 25 transforming the Boards into 18 Health and Social

Services Agencies

BILL 25: A new reform of regionalization

Bill 25: Transformation of the regional governance structures

Transformation of the Health Boards into Agencies:– Former mandates and powers remain for at least

2 years– New mandate: development of Local Services

Networks

Long-term Care Centre(CHSLD)

HospitalLocal Community

Service Centre (CLSC)Health and Social Services Centre

(HSSC)

Bill 25: Development of Local Services Networks

LOCAL TERRITORY

GOVERNMENTAL AGENDA: 1980s-2002

How the problem emerged?

Health reforms of the 1990s– Mergers & service integration

Clair Commission of 2000– Criticizes regional boards

Introduction of Bill 28 in 2001– Brings changes to governance (boards)

DECISION AGENDA: 2002

Quebec Liberal Party electoral platform

At the end of 2002, the Liberal Party presented their electoral platform for the 2003 elections

Content of the platform:– Regional Health Boards were to be abolished – Service coordination was to be transfered to the local health

care institutions– Creation of a 2 tiers system: provincial and local levels

April 2003: Liberal Party wins the elections

POLICY CHOICE: 2003

Elaboration of the project: June – October 2003

June 2003: Ministry of Health starts to work on the elaboration of a reform proposal for the Minister– Influence of Alberta’s regionalization model– Conclusion: regional level is necessary

The Ministry’s proposition was not totally in line with the content of the Liberal Party political platform– Regional authorities remain but are transformed– But → integration of services at the local level

The parliamentary commission: November and December 2003

Few actors supporting the project entirely:– Medical and hospitals associations

Consensus on the objectives of the reform– Service integration– Responsibility for the health of the population

Division and opposition on the means to achieve the objectives

– Transformation of the Boards into Agencies– Institutions mergers (inclusion of hospitals)

The remodeled proposition

Bill 25 was modified following the parliamentary commission

Hospitals can be excluded from the mergers because of: – The absence of such services on a territory– The complexity involved in integrating those

services particularly considering: The size of the territory served by the institution The number or the capacity of the facilities Sociocultural, ethnocultural or linguistic characteristics

of the population served.

THE IMPLEMENTATION OF THE REFORM

Implementation of the reform: January – June 2004

The Ministry of Health implementation strategy:– No standardized model, no precise instructions – Agencies and the local institutions to come up with

proposals on how to configure their local services networks

– Propositions could differ from one territory to another with respect to size of networks, territorial delimitations and type of institutions merged.

Agencies had to submit their regional organizational plans by the end of April.

Implementation of the reform: January – June 2004

The proposals were studied by the Minister of Health between April and June

A few changes were made to the initial proposals submitted by the Agencies

June 23rd 2004:– 95 Health and Social Services Centres (HSSCs)

were created and more than 700 new board members were appointed.

Since July 2004…

Development of clinical projects Introduction of Bill 83 in November 2005

– Regional level of governance survives

Before/after

MAY 2004

452 institutions 328 public 124 private

JUNE 2005

357 institutions 95 HSSCs

– 79 including an hospital

100 public– 32 hospitals– 12 long term care facilities– 40 rehabilitation centres– 16 youth centres

122 private

CONCLUSION

Key success factors

Major reform, quick reform

Military commando strategy

Bill 25 or the «let’s do it» law

Clear consensus on the targeted objectives

Key success factorscontinued...

Minister of health’s credibility & personality

Support from key actors

Support from the Agencies A good political process:

– Strategic support– Timing– Willingness– Opening

Challenges ahead

Protecting primary care, health promotion and prevention

Future of the regional level Integration & networks Getting health professionnals on board Time for transition of management teams Financing

Conclusion: Innovation and continuity

An innovative reform to improve health services

A reform in line with Quebec’s regionalization heritage

No changes to core features of regionalization model:– Region’s boundaries– 3 tier system of governance

THANK YOU!

QUESTIONS AND COMMENTS?