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Process Issues in Vertical/Horizontal Integration for Multiple Intervention Programs Print E-mail

Integrated Strategy on Healthy Living and Chronic Disease. Process Issues in Vertical/Horizontal Integration for Multiple Intervention Programs

Speaker: Tim Hutchinson

Day 2 of the Symposium began with a presentation and discussion of process issues related to vertical and horizontal integration for MIPs. The first speaker, Tim Hutchinson provided a comprehensive overview of the Integrated Strategy on Healthy Living and Chronic Disease (ISHLCD) of the Public Health Agency of Canada (PHAC), identifying the key areas where integration has played a significant role in the success of the development and implementation of the strategy and the organization put in place to oversee it. He reinforced the notion that defining integration has been a challenging but essential aspect of the success of the ISHLCD – a very ambitious multiple intervention program. He emphasized the need to talk about structure when discussing process, and the importance of context, such as changes in governments and the election environment of a minority government.

The ISHLCD began with public health thinking about multiple intervention programs, with particular attention on how to address issues of meshing common risk factors across a number of public health functions and how to operationalize the strategy using an integrated framework. Hutchinson presented the conceptual framework for the Strategy and pointed to the important aspects of integration represented in it. For example, he talked about integration within and across local, provincial/territorial and national jurisdictions; inter-and intra-sectoral engagement in varied settings; and the interface between public health and health care. Hutchinson discussed the development and operationalization of a Strategy matrix (the blueprint or ‘placemat’) that demonstrated integration across and within program components and functional components. He explained the integration between functional components and also the synergies that existed between the programs through each of the functional components.

Hutchinson raised many probing questions related to integration, indicating the depth of thinking that has gone into the integrative focus of this Strategy. As an example, he asked: “How do you use your surveillance data that comes together with your KDED (Knowledge Development, Exchange and Dissemination) pieces (that is, emerging best practices) and your program pieces, and how do these work together in a way that your surveillance is informing the other components?” Further challenges associated with integration included the possibility of too much communication; the amount of engagement needed; the costs associated with integration; and the importance of determining and operationalizing roles and responsibilities. Hutchinson also commented that organizations can get lost in the structure when trying to operationalize complex and integrated systems.

The Strategy led to putting a coordination structure in place to ensure congruence and consistency. Hutchinson suggested that it is easier to work across sectors because roles are clearer. However within one’s own sector, interesting dynamic issues exist that pose real challenges in operationalizing integrated ways of working, including determining the degree of interpretation and competition.

He also talked about the Strategy’s logic model and how it provided a sense of how various components ‘meshed’ and demonstrated the development of program elements in an integrated way. Through ongoing monitoring and evaluation and implementation reviews, integration has evolved, building on internal collaboration and working towards broader scale integration. Hutchinson emphasized the importance of having a framework (the matrix) that keeps the Strategy focused on both vertical and horizontal integration, knowledge development and cross-functional work.

Hutchinson concluded by summarizing lessons learned about integration and multiple intervention programs as the ISHLCD has been developed and implemented. Some components have been successfully integrated vertically – the surveillance and KDED functional components and diabetes community-based programming. An example of horizontal integration, the Healthy Living Fund has been successfully implemented across sectors. Overall progress has been made in engagement, reach, and partnerships. “Being true to principles is what ultimately makes for effective integration” was the final message that Hutchinson offered participants.

Discussants: Caroline Andrew and Louise Lemyre

In their comments, discussants Caroline Andrew and Louise Lemyre brought unique but extremely relevant perspectives to the discussion. Andrew organized her remarks around one definition, two perspectives and three lessons. She identified governance (the effective mechanisms of coordination in situations where power, resources, and information are widely distributed) as particularly relevant to the discussion of process issues of integration and the ISHLCD. She suggested that we don’t know enough about coordination mechanisms – which ones work and which ones don’t; who should be involved and who decides; and how clear/vague mandates are.

Andrew then provided two perspectives on the Strategy matrix in the context of effective mechanisms of coordination. As she reflected on earlier discussions about approaches to integrative interventions, Andrew‘s first perspective was on place-based policy, commenting that the Strategy matrix importantly allows for continuous effort of federal capacity building of local governments and communities. However, she questioned how the model coordinates the three distinct community-based programs, commenting that they were each disease specific and did not seem to relate to other broader issues at the local level.

The second perspective reflected Andrew’s particular interest in the needs of groups such as immigrant women in the health care system, involving politics, advocacy, open systems, and multiple actors. She asked how that perspective works its way into the ISHLCD matrix, into mental health, and into knowledge. If one thinks of flexible and open systems of integration, how do these political points of view get worked into integration? She suggested that the challenges of intersectionality and the multiplicity of identities require that numerous groups need to understand how to intervene.

Lessons gained from Hutchinson’s presentation included the importance of good federal programs for place-based policy making and good federal coordination with key players focussed on capacity building. The second related to the current constraints of Canadian federalism. She suggested that issues of jurisdiction are important, asking what the relationships between communities and municipalities are and should be. There is currently a (provincial) blank space in how we think about place-based vertical and possibly horizontal integration. Lastly, Andrew felt it is important for the federal and provincial governments to think about their evolving roles in place-based policy making. Changes from top down processes to partnering are required. Returning to the issue of immigrant women, Andrew concluded by asking how the priority of mental health of immigrant women could be advanced in the ISHLCD. Are governments thinking about new ways to relate in this vertical and horizontal integration strategy?

Louise Lemyre provided comments from the perspective of ‘her context,” that being of developing interventions to integrate psychosocial considerations into planning and managing of risks in areas such as Chemical, Biological, Radiological, and Nuclear Explosive (CBRNE) terrorism, pandemic planning, natural disasters, and major events like the Olympics. Lemyre commented that she is trying to promote an ecology of systems very much like multiple interventions, which includes targeting multiple levels. Other important aspects of the ecology of systems are the ripple effects of one risk or event on others, and thinking ahead of the curve. She is implementing this system in the training of scientists, first responders, health workers, the public, the media, and decision makers. This training is carried out vertically (by government jurisdictions and by public, private, and NGO levels) and horizontally (by sector, e.g., health, transportation, etc.).

Lemyre emphasized the need to view interventions in context, using a photograph of rain droplets in water as a way of thinking about what multiple interventions and their evaluations look like. She suggested it is like asking “which of the droplets is effective in getting me wet?” If we want to foster an ecological system, we cannot only use the system to structure interventions – the process has to be more organic. There is a tacit biomedical paradigm used in multiple interventions: looking for ‘prescriptive’ doses; looking for fidelity instead of agility of interventions; and an emphasis on top-down, unidirectional approaches where there is little input and some consultation, but not real engagement. Lemyre suggested that we should be implementing multiple patient interventions at many levels.

She stated that processes are critical and should be considered the dependent variable in interventions. Interaction and awareness are essential and knowledge must become much more organic. It is in the very engagement of the people to whom one would apply a treatment (or intervention) that the ‘active ingredient’ resides, and it is when stakeholders understand the real factors and pathways (i.e., important experiential knowledge) that things begin to change. Missing processes include co-ownership of issues and solutions; social identity; and experiential processes that are organic.

In reframing intervention processes, Lemyre concluded by proposing the use of the term “circum-vention” rather than intervention. In this way, we pursue engagement and reciprocity and through interaction and shared knowledge, we will learn to share issues and eventually find shared solutions.