Journey Through the Fractalization of Multilevel Governance: Levers for Adapt Healthcare Organizations Toward Migrant Populations in Canada.

This article focuses on multilevel governance applied to health organizations in Québec (Canada). The objective is to understand the action levers that facilitate the adaptation of the services toward migrant populations. This type of population establishes itself as an excellent tracer case to analyze the adaptation process, its fractalization and its involvement with the Environment. The dynamics between the actors and their self-organization takes part in the development of a multilevel governance. Interactions with the Environment-both internal and external-highlight the development of networks that emerge from the field and are then implemented at strategic levels in the organizations. The presence of connectivity actors within the organization and the Environment is established. The context, the bonds of trust between the actors and the credibility of the policymakers are reflected as important factors. However, connectivity actors cannot be successful without the support and contribution of the more "hierarchical" actors. Eight action levers are revealed by the analysis. We categorized them in 3 functions: administrative, enabling, and emerging. The levers of the administrative and emerging functions require that the levers of the enabling function be credible and legitimate and be able to support them for the adaptation to spread throughout the healthcare organization, regardless of the scope or policymaking level. The fractal function facilitates this process, by combining connectivity actors with the implementation of connectivity structures.

The Influence of Individuals' Vulnerabilities and Their Interactions on the Assessment of a Primary Care Experience.

This study examines the relationship between the vulnerabilities of individuals and their assessments of their primary care experiences in the setting of a universal care system. It focuses on 2 specific objectives: (1) evaluating the influence of each of the 5 vulnerabilities on the assessment of the care experience; (2) evaluating the influence of the interactions between the different types of vulnerabilities on the assessment of the care experience. The study identifies the primary care experience of 9,206 people. The health-related, biological, material, relational, and cultural vulnerabilities are also evaluated. Generally, individuals' vulnerabilities are associated with a positive assessment of the primary care experience except for the cultural vulnerability. Material vulnerability is most frequently associated with a positive assessment of the primary care experience. The interactions between the multiple vulnerabilities present for one individual often modify the effect of vulnerability on the assessment of the experience of care. The positive effect of a vulnerability on the assessment of the care experience often increases in the presence of a second vulnerability, especially the health-related vulnerability. The simultaneous presence of health-related vulnerability cancels the negative influence of cultural vulnerability on the assessment of the primary care experience.

Health care system performance of 27 OECD countries.

The article is based on a multidimensional conception of healthcare system performance. Our objectives are to assess the performance of the healthcare systems of 27 Organisation for Economic Co-operation and Development (OECD) countries and to discern the countries' profiles according to the homogeneity of their healthcare systems' levels of performance. The analyses were carried out on data collected from the 27 high-income OECD countries, primarily using the OECD Health Data 2007 database, the World Health Organization 2008 statistics, OECD Health at a Glance and OECD Social Indicators. Each healthcare system's performance was assessed on the basis of the volume of available resources, services produced and health outcomes achieved and efficiency, effectiveness and productivity, thus characterizing the investments made in proportion to the available resources and services produced. Overall performance profiles were constructed taking into account simultaneously the level of all these components. Using multiple clusters analysis, we were able to group the countries into four profiles (satisfactory, promising, weak-polarized and limited) according to the homogeneity of their performance levels. This article offers a broad overview of the performance of these healthcare systems. The results will enable decision-makers to know the strengths and weaknesses of their own health care system and also to compare it with those of other countries.

Availability of healthcare resources, positive ratings of the care experience and extent of service use: an unexpected relationship.

Two main avenues are advocated to improve the capability of healthcare systems to satisfy the public's needs and expectations: more resources and better organization. This paper sheds some light on this debate. It assesses the extent to which patients' positive rating of their healthcare experience and the extent to which they use services are related to the availability of healthcare resources. Findings indicate that patients' evaluations of their care experience and use of services were higher when the availability of resources was either limited or average. In no case were positive ratings of services and greater use of them associated with greater resource availability. Thus, simply adding resources runs the risk of diminishing, rather than improving, users' healthcare experience.

The experience of primary health care users: a rural-urban paradox.

INTRODUCTION: We sought to assess the care experience of primary health care users, to determine whether users' assessments of their experience vary according to the geographical context in which services are obtained, and to determine whether the observed variations are consistent across all components of the care experience. METHODS: We examined the experience of 3389 users of primary care in 5 administrative regions in Quebec, focusing on accessibility, continuity, responsiveness and reported use of health services. RESULTS: We found significant variations in users' assessments of the specific components of the care experience. Access to primary health care received positive evaluations least frequently, and continuity of information received the approval of the highest percentage of users. We also found significant variations among geographical contexts. Positive assessments of the care experience were more frequently made by users in remote rural settings; they became progressively less frequent in near-urban rural and near-urban settings, and were found least often in urban settings. We observed these differences in almost all of the components of the care experience. CONCLUSION: Given the relatively greater supply of services in urban areas, this analysis has revealed a rural-urban paradox in the care experience of primary health care users.

Is it really the tail that wags the dog?

Brian Hutchison views the numerous initiatives on primary healthcare in provinces and territories as indications that transformative changes are finally under way in Canada. Changes are indeed occurring. New primary healthcare models are being introduced. One could question whether they are the most promising models and whether they have the characteristics to become performing ones. These initiatives are being taken precisely at the time when the performance of the Canadian healthcare system is at the bottom. But performance was a lot better long before these changes were being introduced. Something else is at play in shaping the Canadian healthcare system, which involves but goes beyond primary healthcare: a tilting healthcare system. Unless a rebalance in favour of primary healthcare is accomplished, it is unlikely that the introduction of new PHC models alone could make the difference.

Primary care practice a la carte among GPs: using organizational diversity to increase job satisfaction.

BACKGROUND: Primary care revival in Canada and elsewhere is viewed by many as conditional to the introduction of new organizational models. Endorsement by GPs is a key factor in the success of these models, and increasing GPs' job satisfaction is often one of the desired outcomes of the reforms currently underway. OBJECTIVES: The phenomenon of work satisfaction from the GP's perspective is not yet fully understood. The objectives of this study were to elicit its different facets and to understand better how organizational factors affect it. METHODS: This is a case study carried out in the province of Quebec (Canada). We conducted semi-structured interviews with 28 GPs working in private clinics and community health centres (Centre local de services communautaires). RESULTS: The main themes uncovered are related to the relationship between time management and quality of care, variation in work, autonomy in day-to-day practice, team 'orientedness' and social rewards. We also found that some GPs prefer to combine work in different organizations and models in order to increase their job satisfaction and to better cope with an increasingly complex task environment. CONCLUSION: Our study provides a comprehensive view of the various dimensions that GPs consider important in their professional life. Our findings suggest that, for many GPs, the perfect practice is tailor made and implies a combination of organizational models in order to fulfil their multiple professional goals. This has important implications for decision makers who are promoting new primary care models.

[Integrating prevention and promotion in health systems: four realities, diverse similarities]. / L'intégration de la prévention et de la promotion dans les systèmes de santé: quatre réalités, plusiers similitudes.

The Forum Dialogue on national health systems which took place as a satellite meeting of the 2nd International Conference on Local and Regional Health Programmes compared four countries (Brazil, France, Switzerland and Canada) sustain "conditions to integrate prevention and promotion in health systems". Despite the diversity of the four systems presented, several similarities regarding difficulties faced and achievements obtained in the integration process have been extracted, which has allowed highlighting three perspectives of action. It is suggested that prevention and promotion can be integrated into health systems by mobilising the population and health professionals towards prevention, but with the condition that the promotion and prevention sector increase its credibility by developing practices of quality, organisation, discourse, and prevention practices adjusted to the health care context. Finally, exchange between the countries on this subject is the way forward to nourish the thinking and support each other to obtain this desired integration.

Desarrollo de la acción y el compromiso intersectorial / Action development and intersectorial commitment

Este documento está concebido como herramienta para las IESP, a fin de estimularles el pensamiento, la discusión y la acción sobre su función en el desarrollo de la acción intersectorial. Resume las bases para la acción intersectorial. Aporta una síntesis de lo que es la acción intersectorial (la definición); lo que incluye (los componentes esenciales) y lo que implica (las condiciones para el éxito), Sugiere las formas como las IESP pueden fomentar y apoyar la acción intersectorial. Señala que los retos para estas instituciones son tanto teóricas como prácticas. Incluye, mediante la investigación, el desarrollo de una base de conocimiento para mejorar la acción y el compromiso intersectorial. También, incluye la transferencia y utilización de este conocimiento mediante la educación, el adiestramiento, la actividad comunitaria directa y la cooperación técnica