How can entrepreneurs experience inform responsible health innovation policies? A longitudinal case study in Canada and Brazil.

AIM: To foster equity and make health systems economically and environmentally more sustainable, Responsible Innovation in Health (RIH) calls for policy changes advocated by mission-oriented innovation policies. These policies focus, however, on instruments to foster the supply of innovations and neglect health policies that affect their uptake. Our study's aim is to inform policies that can support RIH by gaining insights into RIH-oriented entrepreneurs' experience with the policies that influence both the supply of, and the demand for their innovations. METHODS: We recruited 16 for-profit and not-for-profit organisations engaged in the production of RIH in Brazil and Canada in a longitudinal multiple case study. Our dataset includes three rounds of interviews (n = 48), self-reported data, and fieldnotes. We performed qualitative thematic analyses to identify across-cases patterns. FINDINGS: RIH-oriented entrepreneurs interact with supply side policies that support technology-led solutions because of their economic potential but that are misaligned with societal challenge-led solutions. They navigate demand side policies where market approval and physician incentives largely condition the uptake of technology-led solutions and where emerging policies bring some support to societal challenge-led solutions. Academic intermediaries that bridge supply and demand side policies may facilitate RIH, but our findings point to an overall lack of policy directionality that limits RIH. CONCLUSION: As mission-oriented innovation policies aim to steer innovation towards the tackling of societal challenges, they call for a major shift in the public sector's role. A comprehensive mission-oriented policy approach to RIH requires policy instruments that can align, orchestrate, and reconcile health priorities with a renewed understanding of innovation-led economic development.

Comparing Health Workforce Policy during a Major Global Health Crisis: A Critical Conceptual Debate and International Empirical Investigation.

BACKGROUND: The health workforce is central to healthcare systems and population health, but marginal in comparative health policy. This study aims to highlight the crucial relevance of the health workforce and contribute comparative evidence to help improve the protection of healthcare workers and prevention of inequalities during a major public health crisis. METHODS: Our integrated governance framework considers system, sector, organizational and socio-cultural dimensions of health workforce policy. The COVID-19 pandemic serves as the policy field and Brazil, Canada, Italy, and Germany as illustrative cases. We draw on secondary sources (literature, document analysis, public statistics, reports) and country expert information with a focus on the first COVID-19 waves until the summer of 2021. RESULTS: Our comparative investigation illustrates the benefits of a multi-level governance approach beyond health system typologies. In the selected countries, we found similar problems and governance gaps concerning increased workplace stress, lack of mental health support, and gender and racial inequalities. Health policy across countries failed to adequately respond to the needs of HCWs, thus exacerbating inequalities during a major global health crisis. CONCLUSIONS: Comparative health workforce policy research may contribute new knowledge to improve health system resilience and population health during a crisis.

Strategizing Research for Impact.

In its Strategic Plan 2021-2026, the Canadian Institutes of Health Research - Institute of Health Services and Policy Research (IHSPR) convincingly expresses its desire to expand capacity for applied health services and policy research (HSPR) and better mobilize research results for health system transformation geared toward the Quadruple Aim and health equity for all (CIHR IHSPR 2021). These strategic priorities echo views widely shared within the HSPR community, and we commend IHSPR for its leadership and vision. Recognizing the systemic challenges ahead of us, this commentary considers the HSPR community's capacity to achieve the promise of learning health systems, given the obstacles likely to hinder their rapid scale-up over the next five years. Next, we consider the spread of virtual care during the pandemic to illustrate the embedded and negotiated nature of innovation in health systems and the need for vigilance as to the social distribution of their benefits and costs. Finally, a critical review of the strategic plan provides insights into how research is governed in the HSPR field. Based on this analysis, it appears essential to reconsider health system transformation as social system transformation and strengthen interdisciplinary and comparative research. Looking forward, developing a science of science to better understand the conditions associated with high-impact research should be a cross-cutting priority for Canada's HSPR community.

Network-building by community actors to develop capacities for coproduction of health services following reforms: A case study.

INTRODUCTION: Responsive, integrated and sustainable health systems require that communities take an active role in service design and delivery. Much of the current literature focuses on provider-led initiatives to gain community input, raising concerns about power imbalances inherent in invited forms of participation. This paper provides an alternate view, exploring how, in a period following reforms, community actors forge network alliances to (re)gain legitimacy and capacities to coproduce health services with system providers. METHODS: A longitudinal case study traced the network-building efforts over 3 years of a working group formed by citizens and community actors working with seniors, minorities, recent immigrants, youth and people with disabilities. The group came together over concerns about reforms that impacted access to health services and the ability of community groups to mediate access for vulnerable community residents. Data were collected from observation of the group's meetings and activities, documents circulated within and by the group, and semi-directed interviews. The first stage of analysis used social network mapping to reveal the network development achieved by the working group; a second traced network maturation, based on actor-network theory. RESULTS: Network mapping revealed how the working group mobilized existing links and created new links with health system actors to explore access issues. Problematization appeared as an especially important stage in network development in the context of reforms that disrupted existing collaborative relationships and introduced new structures and processes. CONCLUSION: Network-building strategies enable community actors to enhance their capacity for coproduction. A key contribution lies in the creation of 'organizational infrastructure'. PATIENT OR PUBLIC CONTRIBUTION: The lead researcher was embedded over 3 years in the activities of the community groups and community residents. Several group members provided comments on an initial draft of this paper. To preserve the anonymity of the group, their names do not appear in the acknowledgements section.

Appropriating integrated performance management tools in healthcare: a sociomaterial work story.

PURPOSE: The purpose of this paper is to explore the appropriation of control rooms based on value-based integrated performance management tools implemented in all publicly funded health organizations in Quebec (Canada) as a form of legitimate sociomaterial work. DESIGN/METHODOLOGY/APPROACH: Multi-site organizational ethnographic case studies in two Integrated health and social services centers, with narrative process analysis of triangulated qualitative data collected through non-participant observation (163 h), individual semi-structured interviews (N = 34), and document review (N = 143). FINDINGS: Three types of legitimate sociomaterial work are accomplished when actors appropriate control rooms: 1) reformulating performance management work; 2) disrupting accountability work and; 3) effecting value-based integrated performance management. Each actor (tools, institutions and people) follows recurrent institutional work-paths: tools consistently engage in disruptive work; institutions consistently engage in maintaining work, and people consistently engage in creation work. The study reveals the potential of performance management tools as "effective integrators" of the technological, managerial, policy and delivery levels of data-driven health system performance and improvement. PRACTICAL IMPLICATIONS: This paper draws on theoretically informed empirical insights to develop actionable knowledge around how to better design, implement and adapt tool-driven health system change: 1) Packaging the three agents of data-driven system change in health care: tools, institutions, people; 2) Redefining the search for performance in health care in the context of value creation, and; 3) Strengthening clinical and managerial relevance in health performance management practice. ORIGINALITY/VALUE: The authors aim to stimulate new and original scholarship around the under-theorized concept of sociomaterial work, challenging theoretical, ontological and practical conceptions of work in healthcare organizations and beyond.

Field of practice: LARIISA: smart digital solutions to support decision-making in Family Health Strategy management. / LARIISA: soluções digitais inteligentes para apoio à tomada de decisão na gestão da Estratégia de Saúde da Família.

The LARIISA collaborators group has been conducting research and development of technological solutions to support decision-making in health systems since 2009. GISSA, a cloud system resulting from the scientific and technological evolution of the LARIISA project, is among the solutions produced. This paper aims to describe the developing trend of GISSA©, a technological tool supporting the Family Health Strategy in northeastern Brazil, pointing out challenges, paths, and potentialities. This is a descriptive and exploratory study, based on secondary sources from the IBGE, INMET, SINAN, SIM, and SINASC, with quantitative analysis based on machine-learning techniques applied to create digital health microservices. Operating in the northeast and southeast regions, GISSA© provides information that qualifies health managers' decision-making process, improving the municipal health system's management.

O grupo de colaboradores do LARIISA realiza pesquisa e desenvolvimento de soluções tecnológicas para apoio à tomada de decisão em sistemas de saúde desde 2009. Dentre as soluções produzidas está o GISSA®, sistema em nuvem resultado da evolução científica e tecnológica do projeto LARIISA. O objetivo do presente artigo é descrever a trajetória de evolução do GISSA®, ferramenta tecnológica que apoia a Estratégia de Saúde da Família no nordeste do Brasil, apontando desafios, caminhos e potencialidades. Trata-se de um estudo descritivo e exploratório, baseado em fontes secundárias do IBGE, INMET, SINAN, SIM e SINASC, com análise quantitativa a partir de modelos de aprendizagem de máquina aplicados na criação de microserviços em saúde digital. Operando nas regiões nordeste e sudeste, o GISSA® disponibiliza informações que qualificam o processo de tomada de decisão de gestores de saúde e, consequentemente, contribui para aperfeiçoar a gestão do sistema de saúde municipal.

LARIISA: soluções digitais inteligentes para apoio à tomada de decisão na gestão da Estratégia de Saúde da Família / Field of practice: LARIISA: smart digital solutions to support decision-making in Family Health Strategy management

Resumo O grupo de colaboradores do LARIISA realiza pesquisa e desenvolvimento de soluções tecnológicas para apoio à tomada de decisão em sistemas de saúde desde 2009. Dentre as soluções produzidas está o GISSA®, sistema em nuvem resultado da evolução científica e tecnológica do projeto LARIISA. O objetivo do presente artigo é descrever a trajetória de evolução do GISSA®, ferramenta tecnológica que apoia a Estratégia de Saúde da Família no nordeste do Brasil, apontando desafios, caminhos e potencialidades. Trata-se de um estudo descritivo e exploratório, baseado em fontes secundárias do IBGE, INMET, SINAN, SIM e SINASC, com análise quantitativa a partir de modelos de aprendizagem de máquina aplicados na criação de microserviços em saúde digital. Operando nas regiões nordeste e sudeste, o GISSA® disponibiliza informações que qualificam o processo de tomada de decisão de gestores de saúde e, consequentemente, contribui para aperfeiçoar a gestão do sistema de saúde municipal.

Abstract The LARIISA collaborators group has been conducting research and development of technological solutions to support decision-making in health systems since 2009. GISSA, a cloud system resulting from the scientific and technological evolution of the LARIISA project, is among the solutions produced. This paper aims to describe the developing trend of GISSA©, a technological tool supporting the Family Health Strategy in northeastern Brazil, pointing out challenges, paths, and potentialities. This is a descriptive and exploratory study, based on secondary sources from the IBGE, INMET, SINAN, SIM, and SINASC, with quantitative analysis based on machine-learning techniques applied to create digital health microservices. Operating in the northeast and southeast regions, GISSA© provides information that qualifies health managers' decision-making process, improving the municipal health system's management.

Control rooms in publicly-funded health systems: Reviving value in healthcare governance.

BACKGROUND: As part of reforms in 2015, the Ministry of Health and Social Services in Quebec, Canada mandated the national implementation of control rooms, making health system actors accountable for implementing value-based performance management. OBJECTIVE: To explore how do organizational actors appropriate control rooms as managerial tools to influence value-based performance in health systems. DESIGN: Multi-site organizational ethnographic case studies (N = 2) and narrative process analysis of triangulated qualitative data collected through non-participatory observations (179.5 h), individual semi-structured interviews (N = 34), and document review (N = 143). RESULTS: The process of appropriating control rooms plays a crucial role in achieving value-based performance management. Appropriating unfolds along three paths (cognitive, structural, technical) over three phases (implementing, testing, adapting). Implementing control rooms both produces and emerges from improvement capacities within healthcare organizations. Testing tools reveals that incompatibilities between tools, structures and values give rise to value-driven distributed clinical leadership. Adapting tools relies on the adaptability of organizations towards the value system driving the tools, rather than on the adaptability of tools to organizational design. CONCLUSION: There is no "one-size-fits-all" framework to design and support the successful appropriation of control rooms towards achieving value-based performance. However, we believe that consideration for the three distinct phases of appropriation and leveraging the right mechanism to support each phase is a first important step in reviving value in healthcare governance.

Learning from health system reform trajectories in seven Canadian provinces.

In publicly funded health systems, reform efforts have proliferated to adapt to increasingly complex demands. In Canada, prior research (Lazar et al., 2013, Paradigm Freeze: Why is it so Hard to Reform Health Care in Canada?, McGill-Queen's Press) found that reforms at the end of the 20th century failed to change the fundamentals of the Canadian system based on physician independence and assured universal coverage only for medical and hospital services. This paper focuses on reforms since the turn of the millennium to explore the transformative capacities developed in seven provinces within this system architecture. Longitudinal case studies, based on scientific and grey literature, and interviews with key informants, trace the patterns of reform in each province and reveal five objectives that, to varying degrees, preoccupied reformers: (1) address chronic disease, (2) align health system actors with provincial objectives, (3) shift from hospital to community-based care, (4) integrate physicians, and (5) develop improvement capacities. The range of strategies adopted to achieve these objectives in different provinces is compared to identify emerging pathways of reform and extract lessons for future reformers. We find significant cross-learning between provinces, but also note an emergent dimension to reforms, where multiple strategies aggregate through time to create unique patterns, presenting their own set of possibilities and limitations for the future.

Implementing public policy in a non-directive manner: capacities from an intermediary organization.

SETTING: We investigate the capacities of an organization responsible for bridging top-down instructions emanating from a law on public health with the bottom-up realities of health service providers working on population-based health. This article traces the implementation of this law, which requires service-provider organizations to base their actions (planning, prevention, and curative activities) upon the expressed and non-expressed needs of the local population. We investigate a case in the province of Québec that took place over more than 10 years. INTERVENTION: The state strategy involved a key structure: an intermediary organization named IPCDC/KSCDI. We first describe how the organization emerged; the expertise involved from the academic, service, and policy domains; the support provided to service-provider organizations; and the achievements. We then highlight the critical capacities the intermediary organization had to nurture. OUTCOMES: We identify five critical capacities of the intermediary organization: the business intelligence to read and adjust to the given environment of certain organizations, a dedication to collective means, a win-win mentality, scientific connectivity, and the animation of safe havens. IMPLICATIONS: It may be important to focus attention on a capacity approach to intermediary organizations. These capacities can potentially enable governmental organizations to compile a stock of resources that can be mobilized and transferred to support future implementations of other reforms. They could also benefit public health partners in the community who collaborate with service providers and actors who aspire to become intermediary organizations. Finally, the performance measurement of implementing reforms in a non-directive manner could be based on indicators related to these five critical capacities.

Collaborative governance in the Quebec Cancer Network: a realist evaluation of emerging mechanisms of institutionalization, multi-level governance, and value creation using a longitudinal multiple case study design.

BACKGROUND: People living with and beyond cancer (PLC) receive various forms of specialty care at different locations and many interventions concurrently or over time. They are affected by the operation of professional and organizational silos. This results in undue delays in access, unmet needs, sub-optimal care experiences and clinical outcomes, and human and financial costs for PLCs and healthcare systems. National cancer control programs advocate organizing in a network to coordinate actions, solve fragmentation problems, and thus improve clinical outcomes and care experiences for every dollar invested. The variable outcomes of such networks and factors explaining them have been documented. Governance is the "missing link" for understanding outcomes. Governance refers to the coordination of collective action by a body in a position of authority in pursuit of a common goal. The Quebec Cancer Network (QCN) offers the opportunity to study in a natural environment how, why, by whom, for whom, and under what conditions collaborative governance contributes to practices that produce value-added outcomes for PLCs, healthcare providers, and the healthcare system. METHODS/DESIGN: The study design consists of a longitudinal case study, with multiple nested cases (4 local networks nested in the QCN), mobilizing qualitative and quantitative data and mixed data from various sources and collected using different methods, using the realist evaluation approach. Qualitative data will be used for a thematic analysis of collaborative governance. Quantitative data from validated questionnaires will be analyzed to measure relational coordination and teamwork, care experience, clinical outcomes, and health-related health-related quality of life, as well as a cost analysis of service utilization. Associations between context, governance mechanisms, and outcomes will be sought. Robust data will be produced to support decision-makers to guide network governance towards optimized clinical outcomes and the reduction of the economic toxicity of cancer for PLCs and health systems.

What Health System Challenges Should Responsible Innovation in Health Address? Insights From an International Scoping Review.

BACKGROUND: While responsible innovation in health (RIH) suggests that health innovations could be purposefully designed to better support health systems, little is known about the system-level challenges that it should address. The goal of this paper is thus to document what is known about health systems' demand for innovations. METHODS: We searched 8 databases to perform a scoping review of the scientific literature on health system challenges published between January 2000 and April 2016. The challenges reported in the articles were classified using the dynamic health system framework. The countries where the studies had been conducted were grouped using the human development index (HDI). Frequency distributions and qualitative content analysis were performed. RESULTS: Up to 1391 challenges were extracted from 254 articles examining health systems in 99 countries. Across countries, the most frequently reported challenges pertained to: service delivery (25%), human resources (23%), and leadership and governance (21%). Our analyses indicate that innovations tend to increase challenges associated to human resources by affecting the nature and scope of their tasks, skills and responsibilities, to exacerbate service delivery issues when they are meant to be used by highly skilled providers and call for accountable governance of their dissemination, use and reimbursement. In countries with a low and medium HDI, problems arising with infrastructure, logistics and equipment were described in connection with challenges affecting procurement, supply and distribution systems. In countries with a medium and high HDI, challenges included a growing demand for drugs and new technology and the management of rising costs. Across all HDI groups, the need for flexible information technologies (IT) solutions to reach rural areas was underscored. CONCLUSION: Highlighting challenges that are common across countries, this study suggests that RIH should aim to reduce the cost of innovation production processes and attend not only to the requirements of the immediate clinical context of use, but also to the vulnerabilities of the broader system wherein innovations are deployed. Policy-makers should translate system-level demand signals into innovation development opportunities since it is imperative to foster innovations that contribute to the success and sustainability of health systems.

Introducing responsible innovation in health: a policy-oriented framework.

The scholarship on responsible research and innovation (RRI) aims to align the processes and outcomes of innovation with societal values by involving a broad range of stakeholders from a very early stage. Though this scholarship offers a new lens to consider the challenges new health technologies raise for health systems around the world, there is a need to define the dimensions that specifically characterise responsible innovation in health (RIH). The present article aims to introduce an integrative RIH framework drawing on the RRI literature, the international literature on health systems as well as specific bodies of knowledge that shed light on key dimensions of health innovations. Combining inductive and deductive theory-building strategies and concomitant with the development of a formal tool to assess the responsibility of innovations, we developed a framework that is comprised of nine dimensions organised within five value domains, namely population health, health system, economic, organisational and environmental. RIH provides health and innovation policy-makers with a common framework that supports the development of innovations that can tackle significant system-level challenges, including sustainability and equity.

Providing Value to New Health Technology: The Early Contribution of Entrepreneurs, Investors, and Regulatory Agencies.

BACKGROUND: New technologies constitute an important cost-driver in healthcare, but the dynamics that lead to their emergence remains poorly understood from a health policy standpoint. The goal of this paper is to clarify how entrepreneurs, investors, and regulatory agencies influence the value of emerging health technologies. METHODS: Our 5-year qualitative research program examined the processes through which new health technologies were envisioned, financed, developed and commercialized by entrepreneurial clinical teams operating in Quebec's (Canada) publicly funded healthcare system. RESULTS: Entrepreneurs have a direct influence over a new technology's value proposition, but investors actively transform this value. Investors support a technology that can find a market, no matter its intrinsic value for clinical practice or healthcare systems. Regulatory agencies reinforce the "double" value of a new technology-as a health intervention and as an economic commodity-and provide economic worth to the venture that is bringing the technology to market. CONCLUSION: Policy-oriented initiatives such as early health technology assessment (HTA) and coverage with evidence may provide technology developers with useful input regarding the decisions they make at an early stage. But to foster technologies that bring more value to healthcare systems, policy-makers must actively support the consideration of health policy issues in innovation policy.

What do we know about the needs and challenges of health systems? A scoping review of the international literature.

BACKGROUND: While there is an extensive literature on Health System (HS) strengthening and on the performance of specific HSs, there are few exhaustive syntheses of the challenges HSs are facing worldwide. This paper reports the findings of a scoping review aiming to classify the challenges of HSs investigated in the scientific literature. Specifically, it determines the kind of research conducted on HS challenges, where it was performed, in which health sectors and on which populations. It also identifies the types of challenge described the most and how they varied across countries. METHODS: We searched 8 databases to identify scientific papers published in English, French and Italian between January 2000 and April 2016 that addressed HS needs and challenges. The challenges reported in the articles were classified using van Olmen et al.'s dynamic HS framework. Countries were classified using the Human Development Index (HDI). Our analyses relied on descriptive statistics and qualitative content analysis. RESULTS: 292 articles were included in our scoping review. 33.6% of these articles were empirical studies and 60.1% were specific to countries falling within the very high HDI category, in particular the United States. The most frequently researched sectors were mental health (41%), infectious diseases (12%) and primary care (11%). The most frequently studied target populations included elderly people (23%), people living in remote or poor areas (21%), visible or ethnic minorities (15%), and children and adolescents (15%). The most frequently reported challenges related to human resources (22%), leadership and governance (21%) and health service delivery (24%). While health service delivery challenges were more often examined in countries within the very high HDI category, human resources challenges attracted more attention within the low HDI category. CONCLUSIONS: This scoping review provides a quantitative description of the available evidence on HS challenges and a qualitative exploration of the dynamic relationships that HS components entertain. While health services research is increasingly concerned about the way HSs can adopt innovations, little is known about the system-level challenges that innovations should address in the first place. Within this perspective, four key lessons are drawn as well as three knowledge gaps.

Regional Governance in Brazil's Unified Health System: a conceptual essay. / Governança regional no Sistema Único de Saúde: um ensaio conceitual.

This article is a conceptual essay aimed at supporting analyses of the regionalization processes implemented in Brazil's Unified Health System, from the perspective of regional governance. The authors conducted a literature review in the social sciences, public administration, and critical geography, focusing on the concepts of governance, territorial governance, and regional governance in the debate on development. In dialogue with these contributions to the analysis of recent regulation and implementation of health sector regionalization in Brazil, with special reference to use of the Organizational Contract for Public Action (COAP) in the country's health regions, the article concludes that the research on governance as a modern approach to linking public policies highlights the timeliness of developing methodologies and critical reflection on the relevant national processes in Brazil for future health sector proposals, thereby pointing to a new stage in the improvement of the Unified Health System.

Governança regional no Sistema Único de Saúde: um ensaio conceitual / Regional Governance in Brazil's Unified Health System: a conceptual essay

Resumo O artigo consiste de ensaio conceitual orientado a subsidiar análises dos processos de regionalização implementados no âmbito do Sistema Único de Saúde, sob a ótica da governança regional. Para isso, realiza revisão bibliográfica de literatura das ciências sociais, da administração pública e da geografia crítica que aborda os conceitos de governança, governança territorial e governança regional no debate sobre o desenvolvimento. No diálogo com os aportes trazidos por estas contribuições para a análise da regulação e implementação recentes da regionalização setorial no país, com especial referência à implantação do Contrato Organizativo da Ação Pública nas regiões de saúde, conclui que a produção científica que vem analisando soluções de governança como forma moderna de articulação de políticas públicas oportuniza a construção de metodologias e uma reflexão crítica sobre os processos nacionais relevantes para formulações futuras setoriais, ensejando uma nova etapa de aprimoramento do SUS.

Abstract This article is a conceptual essay aimed at supporting analyses of the regionalization processes implemented in Brazil's Unified Health System, from the perspective of regional governance. The authors conducted a literature review in the social sciences, public administration, and critical geography, focusing on the concepts of governance, territorial governance, and regional governance in the debate on development. In dialogue with these contributions to the analysis of recent regulation and implementation of health sector regionalization in Brazil, with special reference to use of the Organizational Contract for Public Action (COAP) in the country's health regions, the article concludes that the research on governance as a modern approach to linking public policies highlights the timeliness of developing methodologies and critical reflection on the relevant national processes in Brazil for future health sector proposals, thereby pointing to a new stage in the improvement of the Unified Health System.

Bridging complexity theory and resilience to develop surge capacity in health systems.

Purpose Health systems are periodically confronted by crises - think of Severe Acute Respiratory Syndrome, H1N1, and Ebola - during which they are called upon to manage exceptional situations without interrupting essential services to the population. The ability to accomplish this dual mandate is at the heart of resilience strategies, which in healthcare systems involve developing surge capacity to manage a sudden influx of patients. The paper aims to discuss these issues. Design/methodology/approach This paper relates insights from resilience research to the four "S" of surge capacity (staff, stuff, structures and systems) and proposes a framework based on complexity theory to better understand and assess resilience factors that enable the development of surge capacity in complex health systems. Findings Detailed and dynamic complexities manifest in different challenges during a crisis. Resilience factors are classified according to these types of complexity and along their temporal dimensions: proactive factors that improve preparedness to confront both usual and exceptional requirements, and passive factors that enable response to unexpected demands as they arise during a crisis. The framework is completed by further categorizing resilience factors according to their stabilizing or destabilizing impact, drawing on feedback processes described in complexity theory. Favorable order resilience factors create consistency and act as stabilizing forces in systems, while favorable disorder factors such as diversity and complementarity act as destabilizing forces. Originality/value The framework suggests a balanced and innovative process to integrate these factors in a pragmatic approach built around the fours "S" of surge capacity to increase health system resilience.

Transforming Regions into High-Performing Health Systems Toward the Triple Aim of Better Health, Better Care and Better Value for Canadians.

A study on the impact of regionalization on the Triple Aim of Better Health, Better Care and Better Value across Canada in 2015 identified major findings including: (a) with regard to the Triple Aim, the Canadian situation is better than before but variable and partial, and Canada continues to underperform compared with other industrialized countries, especially in primary healthcare where it matters most; (b) provinces are converging toward a two-level health system (provincial/regional); (c) optimal size of regions is probably around 350,000-500,000 population; d) citizen and physician engagement remains weak. A realistic and attainable vision for high-performing regional health systems is presented together with a way forward, including seven areas for improvement: 1. Manage the integrated regionalized health systems as results-driven health programs; 2. Strengthen wellness promotion, public health and intersectoral action for health; 3. Ensure timely access to personalized primary healthcare/family health and to proximity services; 4. Involve physicians in clinical governance and leadership, and partner with them in accountability for results including the required changes in physician remuneration; 5. Engage citizens in shaping their own health destiny and their health system; 6. Strengthen health information systems, accelerate the deployment of electronic health records and ensure their interoperability with health information systems; 7. Foster a culture of excellence and continuous quality improvement. We propose a turning point for Canada, from Paradigm Freeze to Paradigm Shift: from hospital-centric episodic care toward evidence-informed population-based primary and community care with modern family health teams, ensuring integrated and coordinated care along the continuum, especially for high users. We suggest goals and targets for 2020 and time-bound federal/provincial/regional working groups toward reaching the identified goals and targets and placing Canada on a rapid path toward the Triple Aim.