Making Resource Shifts Supportive of the Broad Determinants of Health - the P.E.I. Experience

by John Eyles | Jan 01, 2001

Key Implications for Decision Makers

  • PEI has recognized that health care is only one of the variables that contribute to people's health. It shifted resources to support some of these other factors (such as social services, income security, and public housing).
  • Each of the new five health care regions in PEI was given block funding so that resources could be moved to fund these broad determinants of health.
  • This study looked at how these allocations were shifted, and if the tools to do so were successfully applied. It found that:
    • Regional governance helped to move towards this goal (although it may lessen inter-regional co-operation).
    • Block funding was considered less useful.
    • Most involved staff, space, equipment and information rather than financial resources.

  • The implications of this research can be generalized to other jurisdictions pursuing a population health approach.
  • Successful resource allocation is complex. Things to consider include:
    • Policy change takes time and is affected by external factors, including political concerns, public opinion, changing provincial budgets, physicians, and union agreements.
    • Factors necessary for success include strong leadership and general acceptance among employees of the idea of population health and new uses for resources.
    • To gain acceptance of the notion of resource shifting, it's best to start with low-profile, informal resource shifts, to show how it can work.
    • Integration of services for clients is necessary for successful resource allocation and it is also one of its most positive outcomes.
    • Evaluation of efforts to shift resources, to assess their impact and the satisfaction of patients and clients, will help win acceptance and approval of the idea.
    • Traditional approaches to budgeting - emphasizing line-by-line accountability for spending - should be changed to allow for the flexibility necessary to permit innovative use of resources.
    • Major change cannot happen without adequate funding for all programs.
    • Physicians, unions, and others affected by the new approach to resource allocation must be brought into the process as partners. If they are not, only marginal changes can be made to the system.

Executive Summary

Context

In population perspectives, health care is seen as one of several contributors to people's health, not as the sole determiner of good health. In such a perspective, it is an important policy consideration to shift some health care resources to other areas that influence people's health. This report explores the way that resources have shifted, and identifies barriers and facilitators to those shifts.

Implications

Policy change takes time and is affected by external factors, including political concerns, public opinion, changing provincial budgets, physicians, and union agreements. Important factors for successful reallocation include strong leadership and general acceptance among employees of the idea of population health and new uses for resources. It is also important to bring in as partners those who are affected by changes, such as unions and physicians.

Results

The health reform of the early 1990s in Prince Edward Island (PEI) emphasized broad determinants of health, client focus in service delivery, pooling of human services, integration and coordination of services, and the establishment of regional governance. PEI created five health regions to provide hospital care, social services, income security, public housing and a range of other services, but excluded physician and pharmaceutical resources and education. Each health region was given block funding to enable resources to be moved to address the broad determinants of health. These reforms largely survived a change in government in 1996. This research set out to discover if cross-sectoral resource allocations had been made in line with the broad determinants of health and if the mechanisms put in place to assist this process, particularly block funding and regional governance, had been successfully applied.

The key informants identified 74 cross-sectoral resource allocations, two-thirds of which involved staff, space, equipment and information. Twenty-five involved financial transfers, mainly within sectors. Some of the financial transfers reallocated money from community programs to hospital care. In fact, most respondents believed that the acute sector had gained most in recent years in PEI, both through cross-sectoral resource allocations and increases provided through the provincial budget. While most cross-sectoral resource allocations occurred within the broadly defined human services system, some involved partnerships and resource sharing with other sectors, particularly education.

Of the instruments put in place to assist moves towards the broad determinants of health, regional governance was seen primarily as a facilitator. It helped ensure intra-regional integration and coordination and could provide local, accountable services to the regional community. It had, however, appeared to lessen inter-regional cooperation and made such programs more difficult to fund and operationalize. Many respondents thought that regional governance required the presence of a strong standard-setting central authority to ensure equity of provision between regions. Block funding was viewed less positively. Some saw it facilitating cross-sectoral resource allocations through providing one budget for a range of services, whereas others saw some of its features - no carry-over, program surpluses going to pay down program deficits in the same health regions, and line-by-line accounting and accountability - as detrimental to population health resource shifts.

Three times as many barriers as facilitators were mentioned by the key informants. Among the facilitating mechanisms was an emerging organizational culture that supports population health. Important features of this culture included committed leadership, big picture thinking, and motivated and enthusiastic staff, willing to work together to integrate services for clients. In fact, greater integration was seen as one of the most positive outcomes of the changes in the human services system.

The barriers were seen to be structural in nature, involving the political nature of health care, public perceptions and preferences, union agreements, physician opposition and level of funding. The nature and context of funding was seen as vital by most informants and it frames many of the implications identified in this report. Budgetary practice and culture shape what can be achieved - if there is no budget line, there is no activity. For those wishing to advocate, nurture and implement cross-sectoral resource allocations in line with the broad determinants of health, it is important to recognize the limits of what is possible (and how they may be increased in scope).

Method

This report presents the results from a case-study of cross-sectoral resource allocation in the human services system in Prince Edward Island. The research builds on previous research that examined the role of block funding as an instrument for implementing health reform, based on a population health approach. It therefore extends and elaborates the pictures we have of cross- sectoral resource allocation in PEI from 1993 to 1999.

During the winter of 1998-99, 58 interviews were held with people in different positions from all five health regions and the Department of Health and Social Services and from various sectors. In spring 1999, a focus group was held to report back on the preliminary findings. This provided a useful data collection tool as well as an opportunity to confirm researcher interpretations. A dissemination meeting that was held in winter 2000 served similar purposes.