1. Local Health Goals and Integration: Using policy research to guide practice Julia Abelson, Ph.D. Centre for Health Economics and Policy Analysis, McMaster University Presentation to alPHa June 12, 2001, Brantford, ON

2. Regionalization, Integration and Health Goals in Ontario regionalization and devolution considered the model through which improved service integration, coordination and rationalization can occur (tailored to local needs) Ontario decides against establishment of RHAs in late 80s and early 90s formal integration has been on and off (and on again…) the policy agenda (i.e., IHSs and IHDSs) regionalization is a well-known feature of Ontario’s health system (e.g.,DHCs, CCACs, RCCs)

3. Ontario context (cont’d) shift from provincial health goals focus of early 90s (e.g., Premier’s Health Council) to health care and hospital restructuring absence of formal institutional structures to pursue broader health agenda provincially and locally

4. How does Ontario compare to other jurisdictions? Institutional structures: –integrated health and social services at the provincial and regional level in PEI, Quebec –provincial health council with mandate for health goals development in NS –provincial health goals in NS, BC –community health boards/councils in NS, BC and Manitoba

5. Other jurisdictions (cont’d) Nova Scotia Provincial Health Council (1990- 1995; re-established in 1997) Mission: -to listen and respond to Nova Scotians -to guide and monitor government decision making on all aspects of healthy public policy -to promote the use of the NS Health Goals as an essential tool to achieve health and well being for Nova Scotians and their communities

6. Nova Scotia (cont’d) Community Health Boards - first established in early 1990s; legislated into formal existence in 2000 - members initially appointed by district health authorities with provision for elections “A community health board shall (a) foster community development that encourages the public to actively participate in health planning and service delivery;

7. NS Community Health Boards (cont’d) (b) construct a community profile that identifies the deficiencies and strengths of the community with respect to factors that affect health, including income and social status, social support networks, education, employment, physical environments, inherited factors, personal health practices and coping skills, child development and health services in the community…”

8. To whom are board members accountable? most board members consider themselves most accountable to all residents of their district/municipality some perceive themselves as accountable to: –ward residents only (for elected reps) –provincial minister of health –local health care providers/organizations

9. How do board members perceive their representative roles? SK board members thought their role was most like that of: School board member (25%) Hospital board member (23%) Member of legislature (14%) Member of Crown corporation (12%) NGO member (11%) (Lewis, Kouri, Estabrooks et al., 2001)

10. What are the governance structures that define boards? is it appointed, elected or a mix? what difference does this make to decision making? democratically elected board members confer “locally generated legitimacy” appointed and elected members don’t behave that differently over time – is this still a goal worth pursuing?

11. Involving the Community in the Development of Local Health Goals Need to consider the following: Who to involve? In what? How? Why?

12. Who to involve? How to achieve a balance between: Citizens/public (service users, caregivers, taxpayers, community members) Experts (lay, technical, provider, non- provider) Stakeholders (those with an interest) Elected officials Who should be involved? Who wants to be involved? Who does get involved?

13. In what? Need to consider who to involve in what roles: –users/caregivers need to provide information about needs, values and preferences –citizens/taxpayers should also have a say in setting priorities and making choices –need to balance provider and technical expertise against provider dominance (especially in health care sector)

14. HOW? Voice or choice? Voice – consultation; providing input without conferring control over final decision (e.g., surveys, town halls) Choice – responsibility; conferring some control over the final decision (e.g., representation, voting, referenda)

15. What are the objectives? to inform, educate and build an active, engaged citizenry to obtain views, ideas, values to conduct a fair and legitimate process to achieve/influence outcome

16. Challenges People get involved in issues that directly affect them (e.g., hospital closures, NIMBY issues) Challenge is to convince them that thinking about and acting on health goals is important and directly affects them – localizing these initiatives will help!

17. Challenges (cont’d) the public is looking for meaningful involvement that will make a difference and wants “accountable consultation” local health goals initiatives may generate expectations that local community can’t meet – be clear about deliverables!!

18. How local factors can influence change Communities may have pre-disposing characteristics that facilitate or impede health goals and local integration Some examples: –historical, cultural traditions such as inter-agency collaboration or competition; elite-driven vs. grass- roots decision making –resistance to change or commitment to innovation –strong local identity/coherent community values –volunteer base, density of networks of local organizations (i.e., community capacity)

19. Local factors (cont’d) Local institutions can act as enablers Examples: –local government –media –community groups –health organizations –local leadership (credible, enthusiastic leaders)

20. Some final reflections local health goals and system integration offer exciting opportunities for Ontario communities clearly articulated health goals need to be linked to local “solutions” that are concrete and achievable – to show people how they can make a difference begin with those that have greatest potential to succeed and build on early successes to engage the community