1. The Reform to Regionalization in Quebec: Towards a New Model of Local Governance in Health Care Elisabeth MARTIN, Ph.D candidate Marie-Pascale POMEY, M.D., Ph.D. Pierre-Gerlier FOREST, Ph.D. 2006 National Healthcare Leadership Conference Victoria (BC), June 12 & 13, 2006

2. Acknowledgments Research project funded by the Canadian Institutes of Health Research Research grant # 136723 Quebec research team: Laval University and University of Montreal

3. 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

4. THE RESEARCH PROJECT

5. 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

6. 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

7. 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

8. 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

9. INTRODUCTION: Regionalization of health services in Quebec

10. 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

11. BILL 25: A new reform of regionalization

12. 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

13. Long-term Care Centre (CHSLD) Hospital Local Community Service Centre (CLSC) Health and Social Services Centre (HSSC) Bill 25: Development of Local Services Networks LOCAL TERRITORY

15. GOVERNMENTAL AGENDA: 1980s-2002

16. 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)

17. DECISION AGENDA: 2002

18. 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

19. POLICY CHOICE: 2003

20. 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

21. 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)

22. 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.

23. THE IMPLEMENTATION OF THE REFORM

24. 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.

25. 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.

26. Since July 2004… Development of clinical projects Introduction of Bill 83 in November 2005 – Regional level of governance survives

27. 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

28. CONCLUSION

29. 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

30. Key success factors continued... Minister of health’s credibility & personality Support from key actors Support from the Agencies A good political process: – Strategic support – Timing – Willingness – Opening

31. 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

32. 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

33. THANK YOU! QUESTIONS AND COMMENTS?