Advancing the Population Health Agenda

Advancing the Population Health Agenda

ORIGINAL ARTICLE Advancing the Population Health Agenda by Alan Davidson Alan Davidson is an Associate Professor of Health Studies at UBCOkanagan. H...

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ORIGINAL ARTICLE

Advancing the Population Health Agenda by Alan Davidson

Alan Davidson is an Associate Professor of Health Studies at UBCOkanagan. He previously served as Dean of Health and Social Development, Okanagan University College, Director, Health Services, Government of Yukon, and Regional Administrator, Yukon Region, Health Canada. Davidson holds a PhD in Health Care and Epidemiology from the University of British Columbia.

Abstract Using the case of the B.C. Interior Health Authority, the paper teases out some of the bases for practical success and failure in advancing population health in a regionalized health system. Résumé À partir du cas de la B.C. Interior Health Authority, l’article fait ressortir certaines bases de succès et d’échecs pratiques dans le contexte d’un effort pour faire progresser le programme de santé de la population dans un système de santé régionalisé.

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arly studies suggested regionalization is inimical to public health in general and to a population health perspective in particular.1 Researchers argued that regionalization entrenched the conventional public health focus on communicable disease control. Further, according to critics such as Michael Rachlis, provincially mandated integration under hospital auspices would inevitably impose costs to public health’s identity and its claims on resources. In other words, integrated health regions would be hospital dominated and, consequently, would operate to make public health the handmaiden of the healthcare delivery system.1 Regionalization was also thought to jeopardize the development and enforcement of province-wide public health programs and standards. At the micro-level of resource allocation within a health region, the tyranny of the urgent, such as an emergency room crisis, would always threaten to trump funding lengthy community interventions with uncertain results. Yet provincial governments argued that regionalization was pursued as a vehicle to drive the population health agenda. The provinces undergoing major structural reforms in the 1990s, that is, all Canadian provinces except Ontario, claimed a major goal was the re-orientation of the health system away from health services for individuals and toward determinants of health for populations. But was this merely rhetoric as many critics claimed? This paper argues that the relationship between population health and regionalization is not as straightforward as assumed, nor are the relationships between service integration and public health one-way. The story is more complicated and nuanced, and the prognosis for public health in general and population health in particular is better than the literature suggests. The counter story will be told in several parts. First, the paper looks at some of the conceptual issues regarding regionalization and population health. Second, it investigates the development of public health initiatives in the B.C. Interior Health Authority (IH) and their relationship to a population health perspective. Third, it teases out some of the bases for practical success and failure in advancing population health in a regionalized health system.

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What is a Population Health Perspective? The hallmark of “population health” is its attention to collective variables such as societal level determinants of health, including cultural, social, economic, and spatial variables of neighbourhood, housing, physical environment, and community resources. Also central is the claim that healthcare services operate at the individual level as only one determinant of human health. From this perspective, health policy is multi-sectoral and collaborative and finds application at the neighbourhood, community or regional level. The view contrasts sharply with the established healthcare service orientation. It also contrasts with the classic health promotion framework with its emphasis on personal lifestyle and behavioural issues. Both the established healthcare service and the classic health promotion perspectives are individualistic, whereas the population health perspective is collectivist, that is, it operates at the conceptual level of groups of varying size.2 This of course aligns well with public health thinking. Within population health there are camps, indeed schisms.3 The main divide is between quantitative researchers from an epidemiological background who emphasize the effects of structural variables on populations. They are squared off against public health advocates who combine the theory of population health with the valuesbase of the community health framework – equity, solidarity, participation, and accountability. This latter group has a broader view of health, measuring health as a resource for living rather than as a function of disease incidence or longevity. Stated most simply, from the advocacy perspective, the proper object of health policy is citizen enablement to lead healthy lives within healthy communities. The fate of this broader, action-oriented conception of policy (often called “the new public health”) is the subject of interest for this paper. Regionalization, Integration, and Population Health The historic fragmentation of responsibility for the health of residents of a given locale made it virtually impossible for any one health-related service to take into account community-wide risk factors. In the view of provincial policy-makers, fragmentation not only blocked consideration of the broader determinants of health, but also contributed to Balkanisation, which in turn inhibited multi-sectoral collaboration. By 1990, interest in determinants of health was displacing policy interest in healthcare services as the latter, medical and hospital services, were becoming less relevant to a rapidly ageing population for whom chronic disease and multiple health challenges were the major issues. Fragmentation and the associated stove piping became bugbears for ministries of health because they were seen as a major source of system inefficiency. Service fragmentation was addressed by mandated integration. The epidemiological transition was addressed by government advocacy of a population health approach. Politically, both reducing fragmentation and advancing population health found policy expression in regionalization. 18

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Service integration per se does not require regionalization and may occur without it, as it has in Ontario. There is, however, a relationship. Integration and the population health perspective bear contingent relationships with one another and with regionalization. Integration is consistent with the population health tenet that healthcare services are only one determinant of a population’s health. Construing hospital and medical services as determinants on par and in interaction with other important population health determinants leads naturally to the strategic decision to put as many determinants of human health as possible under common management, informed by common goals. Regionalization is, among other things, an approach to service integration. It is the integration of a specified range of services over a bounded, geographically defined area. In other words, while regionalization is not a necessary condition for population health, the co-ordinated approach it drives is. Likewise, conceptually, regionalization does not imply population health. However, the dynamics of geographically defined service units focus attention on communities and the health of groups within the region’s boundaries, thereby contributing to a shift in thinking from individual attributes to more collective ones of populations and places. Public health has been regionalized for decades. But it was not integrated with other health-related activities. The historic regionalization of public health sat well with the fact that many public health goals, in contrast to the goals of healthcare service, are collective, public goods, such as a safe water supply. Even services provided to individuals that look like analogues of healthcare services, the paradigm one being immunizations, are very different in their logic from healthcare. The objective of immunization is to create a large enough pool within a population to achieve herd immunity. The point is not to intervene at the individual level to attain an individual result but rather to influence population-level health outcomes. This observation highlights an interesting feature of the population health perspective. Population health in effect fuses public health with healthcare services by construing the latter, healthcare services, as one of the determinants of the former – the overall health of the population. The position is controversial as it suggests that individual healthcare interventions are valued only when they lead to positive differences in the health of a population. Here we see the critical link between population health and evidence-based health services. Among the implications are comparing the cost-effectiveness of individual-level interventions not only against one another, but also against community-level ones. Those potentially include interventions in housing, or recreation or education or incomes policy – any one of which might have a greater impact on population health than healthcare services. On the one hand, there is a threat to the status and legitimacy of claims on resources made by health professionals and healthcare unions. On the other, legitimacy is conferred on public health and with it the potential for larger shares of health-related spending.

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Expressing matters this way brings out the ideological nature of the policy dispute. The ideas supporting access to healthcare services and those comprising a population health perspective link to the material interests of different parties within society and within the health system itself. That linkage makes policy change very difficult because the interests of powerful groups are affected by policy change. Hence reforms involving competing policy perspectives are resisted and frequently fail.4 While new public health and the conventional health services policy perspectives are genuinely different and may fuel ideological conflict, there are in fact points of overlap. One is the case where a population-level intervention has knock-on effects for healthcare services. An example is an influenza immunization blitz. The strategy is legitimately population health but an outcome is reduced pressure on emergency departments and medical wards. A public health strategy designed to reduce hospital costs as well as improve population health is more obvious to decision-makers (and more likely to be implemented effectively) where acute care, longterm care, and public health services are integrated. It is therefore no surprise that studies in Alberta and Saskatchewan show regionalization has facilitated influenza immunization of older adults.5 While exploiting overlaps might be construed as hospital and medical services channelling public health into serving their interests, there is an alternative, strategic way of viewing interventions that demonstrably reduce institutional care burden. Advocates of the new public health can seize on such overlaps to demonstrate the practical value of population health initiatives to regional managers and boards of governors. This is a point to which the paper will return with a discussion of IH’s “wedge model.” The Case of the B.C. Interior Health Authority The B.C. Interior Health Authority serves a client population of over 700,000 people residing in south central and southeastern B.C. IH is responsible for acute care, mental health, public health, home support and community care, as well as residential and supportive living facilities. Its 2004/05 budget exceeds $1.1 billion. Turning to the place of population health within IH, documentary evidence of the commitment of the senior management of the B.C. Interior Health Authority to population health is available from the statements of the board chairman and chief executive officer. For example, Alan Dolman, the board chair, is quoted as saying: “It’s too easy to have population health overshadowed by pressing health service issues. A focus on population health is really what matters because this is what will keep people from having to use the health system in the future.”6 Senior management gave concrete support in the form of approximately $750,000 in startup money in fiscal year 2002/03. Management commitment has been made manifest in a concerted effort to build IH capacity to employ more effective population health approaches. Capacity building initially focused on internal organizational capacity building. This

took the form of ramping up research and analysis capability, constructing and analyzing relevant databases, providing knowledge and transferring skills to middle-level managers and field personnel, and forging sustainable partnerships with relevant organizations and units within the IH organization. Much of this activity is centred in the Population Health Planning and Support Unit, founded in 2002, and which received its formal launch in the November 2002 Population Health Conference held in Kelowna. That conference brought the key stakeholders from across a wide variety of sectors together with IH managers and front-line community health personnel from all corners of the region. By the end of 2002, IH adopted a model for improvement, the Population Health Planning and Implementation Cycle, and agreed on three priority areas upon which to focus its efforts from 2003 to 2006: (1) early childhood development, (2) injury prevention, and (3) chronic disease prevention. Chronic disease management subsequently moved from Population Health to the Primary Care Directorate and building capacity for population health was added by the Population Health Unit. Crucially, for each priority, measurable targets were set, responsible agents identified, and budgets allocated. An evaluation plan was also mapped out for all population health-related activity. Of particular interest is “Building Capacity for Population Health.” The goal of the focus area is “to improve the health of the entire population and to reduce inequities in health where they are found” through an objective of building IH’s capacity to employ evidence-based population health approaches. The objective required the creation and dissemination of reliable, comprehensive, and relevant health information, theory, and skill transfer to managers and front-line employees, as well as building coalition support within IH and between IH and community partners. An example is the ongoing collaboration between IH and the North Okanagan Social Planning Council to reduce accidental injury among seniors. Initially, the North Okanagan Falls Prevention Program was piloted using funds from Veteran’s Affairs and Health Canada. The project was refined and extended under a contract between IH and Planning Council in October 2004. The focus shifted to an integrated approach to identifying factors contributing to falls by seniors at home, in the community, and in care settings, identifying evidence regarding prevention, reviewing existing conditions, policies, and practices in light of the evidence, building contacts and networks, developing surveillance tools and systems, launching properly evaluated pilot projects, and disseminating the results. A manager was appointed to sponsor better practices throughout the entire region based on the work of the North Okanagan partnership incubator. What Has Happened to the Expression of a Population Health Perspective in IH Compared With What Has Been Anticipated in the Literature? The first issue raised in the Introduction was whether regionalization would harm the new public health by making the prime directive the short-term reduction of the health Healthcare Management FORUM Gestion des soins de santé – Winter/Hiver 2005

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system’s care burden. The answer is that regionalization per se does not seem to make much difference one way or the other. While it is true that the magnitude of change associated with healthcare reform in B.C. disrupted public health, that disruption was no more intense or extensive for public health than for other healthcare services caught up in regionalization. There is no budgetary or programmatic evidence within IH that public health services were wound up or redirected in favour of medical and hospital ones, although public health was certainly consolidated. The second issue is the predicted negative impact regionalization would have on provincial public health programs and public health standards. Here the evidence runs in the opposite direction to the prediction. First, the B.C. provincial government did a reasonable job of anticipating the need for guidelines and standards. Second, the increased autonomy of regions actually brought focus to areas where more, not fewer, common strategies were necessary to meet emerging health goals. Third, innovations that were now possible within regions could be brought more readily to bear on the whole province through the co-ordinating mechanisms developed among the regions. For example, IH is a leader in B.C. in the field of population health and has managed to push the provincial agenda on this front. It appears that regionalization may have an effect akin to the way federalism in Canada created a context for Saskatchewan to push the federal government on Medicare. Fourth, and perhaps most importantly, regionalization reduced the number of B.C. authorities operating in the public health field – the new regions were few (only six), and of sufficient geographic size, with large enough populations to mobilize coherent, consistent programming. In consequence, public health in B.C. is actually better organized, more consistent, and yet also potentially more innovative, than it was prior to regionalization. None of this means success is somehow assured, but it does mean that regionalization is not the cause for failure. The third issue is the obstinacy of the old policy regime. In the case of Interior Health, population health proponents simply sidestepped the problem of changing the policy paradigm by focusing on internal capacity building. Rather than broad-based external collaboration and partnership building, the architects of the population health initiative focused on infrastructure, training, and select high-profile, high value-added activities. This helped cement relationships with champions within the organization, which in turn allows for growing the health authority’s population health-related activities and increasing the reach outside of the organization. Now, three years into the initiative, the population health advocates have resources, skills, and knowledge to share with potential partners, shifting power and influence in their favour. This may never lead to a total transformation of the health policy perspective, but that scarcely matters if the initiatives succeed and the mindsets of many involved in health-related activities are broadened and refined. The fourth issue is the tyranny of the urgent. Contrary to expectations, in IH, population health has stable, indeed growing, funding and executive support, in spite of the usual 20

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stresses and strains of health authority budgets and acute care deficits. The reason is that people make the difference. There are capable senior managers in IH who champion population health and those directly managing the initiative are energetic and credible. Importantly, the population health initiative managers ensure that there are at least some concrete outcomes everyone agrees to be valuable. That does not mean all initiatives are crafted to serve the machine. What it does mean is that there must be an intelligent balance of short- and longer-term initiatives, and that at least some of the short- and medium-term initiatives must yield widely valued deliverables. This is the only approach that can sustain longer-term organizational support. Practical Bases for Success In a paper entitled “Success or Sell Out,” 7 the Population Health Planning and Support Unit describe their wedge model. In their words, “guided by the determinants of health, we moved forward with a targeted intervention for each key area.” In their example of child health and development, the fat end of the wedge incorporates a range of determinants from income, to education and social supports, physical environment, early childhood experiences, health services, and so on. The thin end of the wedge is a specific target outcome, in this example, 30 fewer low birth weight babies born this calendar year. A clear, achievable target, with a plan and resources attached, builds success and credibility with decision-makers. A well-chosen target that also can be shown to have important knock-on effects for the healthcare system makes the initiative and its proponents valuable to the organization. Doing this, however, does not preclude, indeed it facilitates, working up the wedge by concurrently commissioning research on determinants of child health, disseminating the findings from such research, establishing monitoring and health surveillance, and identifying services and supports that are relevant, and determining how those might be improved in light of the emerging evidence. This is exactly what the population health initiative has done in IH over the past two years, placing the advocates where they can commence work with external collaborators and move from internal capacity building to community capacity building, knowing they have the resources and institutional support to succeed. The Population Health Planning and Support Unit has a cheeky motto to describe their wedge model approach: “Give them what they want but do what we want.” Fortunately, the two go together rather well. Important, focused, short-term initiatives meet critical goals of the organization and build support for the medium- and longer-term goals of the new public health. Donald Light once remarked that advocates of the new public health are a bit like Fins during the Cold War. However, instead of huddling on the frontiers, population health in IH is mainstream yet subversive, conventional yet radical, but above all successful.8 In conclusion, regionalization is neither a driver nor an inhibitor of population health. The relationship between population health and service integration in general, and region-

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alization in particular, is contingent and the actual outcomes depend on a number of other variables. Chief amongst those variables in the case of IH’s success to date are: - champions in senior management - stability in regional management - bright, energetic, and credible advocates in population health working under dynamic leadership - early focus on internal capacity building.9

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Acknowledgments

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The author would like to acknowledge the contributions of Dr. Nelson Ames and his associates in the IH population health initiative to this paper.

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References

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Sutcliffe PR, Deber R, Pasut G. Public Health in Canada: A comparative study of six provinces. Canadian Journal of Public Health 1997;88(4):246-249. Dunn J, Hayes M. Toward a lexicon of population health. Canadian Journal of Public Health 1999; 90(Suppl. 1) (November-December):35-39. Raphael D, Toba B. The limitations of population health as a model for a new public health. In: Health and Social Justice (pp. 410-427). San Francisco, CA:John Wiley; 2003. Davidson A. Dynamics without change: Continuity of

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Canadian health policy. Canadian Public Administration 2004; 47(3) (Fall):251-279. "When Public Health takes a system-wide approach facilitated by regionalization, it results in optimized planning, co-ordination, evaluation and successful outcomes." Neudorf C, Obayan A, Anderson C, Chomyn J. A collaborative systemwide response to influenza outbreak management in Saskatoon Health Region. Canadian Journal of Public Health 2003;94(5):338-340. Population Health Profile, 2004, Kelowna, BC: Interior Health; 2004, p. 5. Ames, N, Beck R. Success or sell out? Engaging a health authority in population health work. Nelson, BC: Interior Health;2004. Light DW. Rhetorics and realities of community healthcare: The limits of countervailing powers to meet the healthcare needs of the twenty-first century. Journal of Health Politics, Policy and Law 1997;22(1)(February):105-146. Some good resources in this regard are Capacity Building in Health Promotion, Better Health Good Healthcare, Australian Centre for Health Promotion, NSW Health (2000), available at http://www.health.nsw.gov.au and the various publications by the Primary and Community Health Branch, Victoria State Government, Australia, available at http://www.dhs.vic.gov. au/phkb.

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