ORIGINAL RESEARCH PAPER
Year : 2007 | Volume
: 20 | Issue : 2 | Page : 49-
Towards Unity for Health: Lessons for Health Development in Canada
N Bolduc, P Grand'Maison
Université de Sherbrooke, Faculty of Medicine and Health Sciences, Sherbrooke, Que., Canada
3001, 12th avenue N, Sherbrooke, Que. Canada J1H-5N4
Introduction: The Sherbrooke-Estrie integrated cardiovascular health program (SEICHP) was developed in the Canadian province of Quebec. It was among the 12 field projects selected in 2001 around the world by the World Health Organization (WHO) to implement the TUFH (Towards Unity for Health) strategy as a way to improve health development responding to people«SQ»s needs through integration of health services and partnership among key stakeholders. SEICHP tailored and applied the TUFH approach. It developed comprehensive and integrated services for people suffering or being at risk of cardiovascular problems in its region of influence. It emphasized complementarity, efficiency of resource use, interprofessional collaboration and partnership. In this, SEICHP complied with TUFH criteria. Information on how it adapted and applied these with relative success is reported.
Lessons for health development: Even though difficulties in evaluation represent a limitation, major lessons learned linked to TUFH criteria include: the necessity to involve the public health and individual health people at all phases of program development and implementation, including the identification of information to be collected; an emphasis on integration brings health professionals to realize the importance of interdisciplinary work and academic institutions to modify their educational programs; restraining and supporting factors to partnership must be considered purposefully to optimize the partnership process; and optimal assessment of impact is difficult to attain.
Conclusion: TUFH gave SEICHP a comprehensive conceptual framework for health development to work with. It had a highly significant impact on its development and provides direction for its future actions.
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Bolduc N, Grand'Maison P. Towards Unity for Health: Lessons for Health Development in Canada.Educ Health 2007;20:49-49
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Bolduc N, Grand'Maison P. Towards Unity for Health: Lessons for Health Development in Canada. Educ Health [serial online] 2007 [cited 2021 Jan 19 ];20:49-49
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The World Health Organization’s “Health for All” strategy (WHO, 1978; WHO, 1981) called for action to ensure universal health. Almost three decades later, healthcare systems around the world fall short in achieving the “Health for All” objectives.
Fragmentation in many areas significantly threatens the health services delivery system. There is an urgent call for more integrated approaches centered on patients and population that strive for comprehensiveness of care and services and professional collaboration. Such approaches are based on a sharing of accepted values, a common vision of the situation, a shared philosophy of intervention, and intertwined actions that demand cooperation between actors (Shortell et al., 2000). These observations are consistent with Canadian situations and orientations (Leatt et al., 2000; Leatt et al., 1995; Romanow, 2002).
The “Towards Unity for Health” (TUFH) (Boelen 2000; 2001a; 2002) strategy aims at eliminating fragmentation and implementing health care approaches that foster unity and a shared agenda for actions in delivering services based on people’s needs and in assuring sustainable health development. This is done through integration, complementary roles of health professionals, partnership and optimal balance among basic values of quality, equity, relevance and cost-effectiveness (Boelen, 2000) and depicted by TUFH case studies (Boelen & Neufeld, 2001; Grand’Maison et al., 2001). In 2001, 12 TUFH field projects were chosen around the world (Boelen, 2001b). They were designed to tailor and apply the TUFH approach and to improve its conceptualization and operational methodologies through research and development in practical projects and settings. One project chosen in Canada was located in the Sherbrooke-Estrie health administrative region of the Province of Quebec. It focused on developing a comprehensive integrated cardiovascular health program (Grand’Maison et al., 2000).
The Sherbrooke-Estrie Integrated Cardiovascular Health Program
The Sherbrooke–Estrie region is a 10,000-km2 administrative health region of 300,000 inhabitants, with Sherbrooke (population: 150,000) as its central city. It is one of 18 health regions in the province of Quebec, Canada. The health care system is publicly funded and patients have free access to all services. More than 40% of the region’s population lives in small communities (less than 10,000 inhabitants) that can be as far as 100 km from Sherbrooke. The Regional Health Authority (RHA) is responsible for assuring coordination in optimally using financial and technical resources. The region includes the Sherbrooke Faculty of Medicine and Health Sciences, a tertiary-care hospital affiliated with the Université de Sherbrooke, an integrated university geriatric hospital–community health center, five other community hospitals–health centers, private medical practices, and a large range of health-related community organizations. The region is relatively self-sufficient in terms of healthcare services, offering almost 95% of the required services. Only very specialized services, such as organ transplantation, require travel to larger cities.
The Sherbrooke–Estrie Integrated Cardiovascular Health Program (SEICHP) is a response to the increasing burden of cardiovascular diseases (Fondation des maladies du coeur du Canada, 2003). It was initiated in 1999 by a small group of experienced cardiovascular health nurses from the Sherbrooke university hospital or from the Sherbrooke School of Nursing. SEICHP is patient and family-centered and fosters empowerment of people. It emphasizes comprehensiveness of interventions, continuity of care, interdisciplinary team work (Klein, 1990), efficiency in resource use and complementarity of actions. It has three major components:
A health promotion, primary prevention, and disease-screening component towards the general population, with a special focus on those at greater risk.
A critical care component for individuals’ ischemic heart disease and cardiac insufficiency.
A rehabilitation component for those who have experienced an acute event.
From 2000 onwards, a cardiovascular patient-centered and interdisciplinary care program was established at the university hospital. It fosters complementarity with community resources through specific actions: increasing the access of community physicians to cardiologists by phone for advice or patient transfer; utilization of an evidence-based standardized evaluation grid to prioritize patients for angiography, PTCA, and cardiac surgery; preparation of patients before cardiac interventions and their post-procedure monitoring and care assured in community hospitals instead of in the university hospital; support of professionals in developing new skills and competencies.
In 2002, the university hospital implemented an interdisciplinary rehabilitation clinic for all post-critical event patients. Progressively, over the next two years, all community health centers in the region offered complementary rehabilitation services with the support of the professionals from the hospital-based clinic for the development of their human resources, implementation of practice guidelines and monitoring/evaluation. Nurses play a pivotal role in these outreach services in the areas of patient education, support and empowerment. They liaise between the patient’s family physician and the personnel at the hospital rehabilitation clinic to ensure continuity of the planned intervention and synergy of actions. They also offer group interventions to help patients live with their diseases and change their lifestyles.
SEICHP was developed using three organisational levels: the strategic level focuses on general directions, policies and formal agreements of cooperation; the tactical level focuses on the development of tools, protocols and information-exchange systems; the operational level focuses on the implementation of direct actions with patients. Deliberate efforts were carried out to ensure that at all levels there was involvement of representatives of the five groups of partners identified in the TUFH partnership pentagon: policy makers, health managers, health professionals, academic institutions and communities (Figure 1).
Figure 1: Organisational model and partners
Indicators for the evaluation of the program processes and outcomes were identified. Program leaders found it useful to plot these on the TUFH health compass (Figure 2). Both qualitative and quantitative data were planned to be collected through interviews, focus groups and questionnaires.
Figure 2: SEICHP Evaluation Indicators and TUFH Health Compass
Meeting TUFH Criteria
Innovative patterns of services for integrating medicine and public health
TUFH argues for interventions targeted to a defined population, the offering of a wide range of integrated services and the use of health information to prioritize actions.
The geography of the Sherbrooke-Estrie area is clearly delineated. The adult (≥18 years old) population was targeted for the first component. For its second and third components, the program targeted patients with ischemic heart disease and/or cardiac insufficiency. The geographically confined regional territory, the presence of only one tertiary-care hospital and the fact that 95% of the population receive their health services in the region made it more efficient to cover all expected patients for these last components.
SEICHP offers a comprehensive range of services covering the continuum of care in cardiovascular health from prevention to acute care and rehabilitation. It provides intertwined individual patient-focused disease-management interventions and population-based interventions. Services emphasize integration, continuity, collaboration and efficiency.
RHA uses population-based information for priority setting, resource allocation, and monitoring. Even though relevant, clinicians find this population information less useful in their day-to-day clinical work and more individual patient-focused information systems and protocols are used by healthcare institutions. Unfortunately, information on ambulatory services was not available.
Implications for health professionals practice and education
TUFH-based projects should advocate new opportunities and modified roles for health professionals stressing the need for and support of a comprehensive approach to health, increased professional expertise, teamwork and complementarity. Health professionals should ideally possess a balance of content expertise - i.e. mastery of a discipline or a technical area - and linkage expertise - i.e. capacity to interact with others (Boelen, 2000).
For the SEICHP, University hospital expert professionals, faculty members and external experts provided the training for the practicing professionals on integrated healthcare services and interdisciplinarity. Physicians, nurses and other health professionals confirmed during informal interview that following training and practical involvement in program activities, they felt more competent in their own roles, more knowledgeable in the role of others in the continuum of care of each patient, and more confident and motivated in performing their tasks.
The University Nursing and Medicine programs also jointly developed, in 2005, a comprehensive program on interprofessional collaboration for their students partially influenced by the program. Clerks, residents, and nursing students in cardiology training rotations were exposed to the newly implemented clinical approaches. During the same period, the Sherbrooke Medicine program committed itself to the integration of public health and individual health in medical education (Donovan et al., 2005) and concretely applied this integration in the teaching of cardiovascular health.
Essential and sustainable partnerships
According to TUFH, the challenge of establishing a sustainable health services delivery system calls for the active contribution of partners. SEICHP involved partners from the five stakeholder groups represented on the TUFH pentagon at all organisational levels. Their contribution was significant and continuous in building collaboration and overcoming difficulties. SEICHP started its activities at the level of ad hoc arrangements based on a small group of individuals committed to cardiovascular health. It progressively became a shared project and then a long-term commitment supported by all regional institutions and stakeholders.
Evidence of impact
While conceptually sound, the evaluation plan was difficult to operationalize. This represents a limitation of the present study. The short period of time (two years) for the implementation and evaluation of a TUFH field project, supported by WHO, limited extensive data collection and analysis. Furthermore, human financial resources were mainly involved in program development and clinical activities implementation, and almost none were specifically dedicated to evaluation. Qualitative data were obtained more informally than through formal process. Baseline quantitative data, covering the period of the end of the 90s and 2000-2001, were obtained on cardiovascular mortality and morbidity, and on patients’ access and use of services (Agence de développement des réseaux de santé et services sociaux, Quebec/Estrie, 2004). The next round of data collection and analysis with a 3-5-year period comparison occurred in 2006 and will not be available for comparison before 2008.
TUFH argues for an optimal balance among four basic values - quality, equity, relevance and cost effectiveness - for which SEICHP identified indicators (Figure 2). Even though measurement of indicators was not as rigourous as it should have been, some conclusions may be derived. Cardiovascular health was confirmed as a regional priority and priority of services was awarded to high-risk populations, confirming SEICHP relevance. Equity was achieved through services being more available, accessible, and adapted to patient location through outreach activities. Health professionals on the various teams shared roles and responsibilities through interprofessional collaboration, thus supporting the cost effectiveness of activities. The intervention strategy optimizing the use of the resources of the community hospitals for patients needing cardiac interventions has a significant impact on the efficiency of the services offered (Do et al., 2006; Maltais et al., 2003). Outcome indicators of cost effectiveness and quality of care are now being collected. Globally, both health professionals and patients have repeatedly confirmed their satisfaction with SEICHP activities and services.
Lessons for Healthcare Project Development
WHO expected that lessons learned from TUFH field projects would contribute to knowledge for developing appropriate methodology for creating unity in health (Boelen 2001b). Lessons were shared among project leaders during meetings (Bryant et al., 2002; Lippeveld & Glasser, 2002; Lippeveld & Glasser, 2003) and project semi-annual reports (Grand’Maison et al., 2001; Grand’Maison et al., 2002; Grand’Maison et al., 2003), or through scholarship dissemination (Grand’Maison & Bolduc, 2004; Bolduc & Grand’Maison, 2005). The following paragraphs present the most relevant lessons learned from SEICHP linked to TUFH criteria.
Public health and curative medicine should be complementary (Lasker, 1997; White, 1991). An important lesson learned is to make sure that public health and individual care people work together from the planning phase to the implementation and monitoring phases of any health development project.
Different stakeholders need different kinds of health information. Their needs must be considered, indicators confirmed, information to be collected prioritized and compromises made so that the optimal level of common and critically needed by all information is attained. Optimal information systems should use routine information and have simple data collection processes, efficient data analysis, and clear, concise presentation of data (Lippeveld et al., 2000).
An understanding of patient needs in the continuum of care and an emphasis on the integration of services help health professionals to realize the necessity of interdisciplinary health care. As it occurred with the SEICHP, involvement of faculty members in such a project such may have a leverage effect on curricular changes in health professions education (Boelen, 1995).
The following barriers to partnership were identified (Bolduc & Grand’Maison, 2005):
Achieving a common vision and even agreeing on words, terms and concepts.
Partners’ prioritization of their own interests and even displaying dominating behaviours.
Failure to accept the asymmetrical nature of partnerships considering partner expertise and issues at stake.
Inadequate partner representation at different organizational levels.
Decision-makers that do not always “walk the talk.”
Changes in key project leaders’ professional or personal situations.
Supporting factors for partnership were also identified:
Focusing on a common goal, harmonizing visions and building a consensus.
Emphasizing each partner’s potential, competence and strengths as well as recognizing limitations.
Creating a sense of coordination and agreeing on priority issues.
Exerting productive leadership.
Ensuring partner collaboration throughout the continuum from conceptualization to practical actions.
Working against a common external threat, a situation frequently leading all partners to pool their strengths.
Similarly to unity, partnership in health development is not an all-or-nothing phenomenon that occurs overnight. Much more than an outcome, it is a long-term, additive, and iterative process. It results only from determination and a purposeful strategy.
Evaluation of a healthcare development project requires time, energy, early planning, clear identification of indicators, robust design and commitment for data collection and analysis. It usually calls for an action-research approach with a pre and post intervention design that necessitates baseline measures. Assessment of processes is continuous while assessment of results is delayed in time. Too frequently, evaluation is not prioritized adequately and lacks recourses, as was learned with SEICHP.
SEICHP committed itself to TUFH. Globally and despite the limitation of its evaluation, we may conclude that it adapted and applied TUFH criteria with relative success. TUFH gave SEICHP stakeholders a conceptual framework in health development to work with. TUFH was useful to clarify concepts, streamline the project, identify strategic orientations, implement concrete actions and build partnerships. Major SEICHP successes include implementation of the various program components, regional deployment, optimal use of resources in both institutions and community, and implementation of services of higher quality and better integrated into a meaningful continuum for all patients. More importantly, program stakeholders have learned to work together and are more committed than ever to collaboration and partnership in their regular work.
Applying the TUFH principles requires a long-term commitment and perspective. Much work still needs to be done to bring SEICHP to its optimal adoption in order to create unity. Even though it may be too early to make a final judgment about TUFH’s concrete and overall impacts, all those involved can confirm that using TUFH has had a highly significant impact on getting the program to its present development and providing the foundation for its future success.
The authors are grateful to the following persons who, due to their leading positions during the 2001-2004 period, were variously involved in developing and implementing the SEICHP: Danielle St-Louis, RN, clinico administrative director of the SEICHP; Louise Rivard, RN, member of the physical health directorat, Regional Health Authority; Michel Nguyen, MD, medical director of the SEICHP; Robert Pronovost, MD, member of the public health directorat, Regional Health Authority; Serge Trachy, RN, assistant CEO, Sherbrooke University Hospital.
Further to be supported by all partners, the present project was made possible through a grant received from the World Health Organization for the 2001-2002 period.
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