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

Structural Issues in Vertical/Horizontal Integration

Speaker: Jack McCarthy

During the third session of the symposium, Jack McCarthy specifically considered structural issues in vertical and horizontal integration for multiple interventions. McCarthy shared learning about horizontal and vertical integration strategies at the community level gained through his work at a local community health care centre. The centre serves as the hub for a number of comprehensive health and social services, and is engaged in community development and policy work. The centre requires networking, planning, advocacy, and co-ordination with various community groups to meet its vision of building healthy communities and promoting healthy public policy. Integration is believed to improve client care through the provision of timely services, appropriate referrals, delivery of seamless care, and system efficiencies. For McCarthy, the issue is not buy in for integration but how to integrate.

Diverse structural barriers pose challenges for integration. Integration is labour intensive and may overload existing mandates. There is an absence of an overarching framework for health goals and of common data management systems. Different governance and legislative mandates and funding mechanisms represent additional structural challenges for integration. Turf protection and institutional behaviour change that is slow to change are also barriers. Yet, we know integration is possible. McCarthy drew on examples of crisis and tragedy to illustrate that no perfect process or operational plan is needed to bring people together to solve community problems. Making integration happen requires creating partnerships, developing common missions, taking risks, and remembering to remain passionate and have fun in the process.

Discussants: Tim Hutchinson and Dominique Tremblay

Tim Hutchinson and Dominque Tremblay provided insightful comments in response to McCarthy’s presentation. Hutchinson identified a number of questions around vertical and horizontal integration inspired in response to the presentation. From a public policy perspective, Hutchinson asked how we measure the various levels of integration described in these complex programs and how we measure successful networks. Although there is no cookie cutter approach, there are common elements and indicators from which we can learn and avoid reinventing the wheel.

Hutchinson was also struck by the importance of figuring out how to measure context in relation to integration. In addition to addressing the community, cultural, and client contexts, there is a need to deal with the changing context that includes both subtle and dramatic shifts. Building answers to these questions into our evaluation frameworks and research agendas would be an important step forward. Hutchinson also spoke of the need to learn more about the levers that pull people together, not only in times of crisis but also during times of opportunity. Understanding what elements of the structure facilitate creativity and responsiveness is an important area to explore. For Hutchinson, a critical structural piece for systems integration is the development and sharing of data sets to maximize synergies and actualize potentials that are possible because of integration.

For Tremblay, McCarthy’s presentation underscored the need for researchers to invest in understanding how successful integration occurs. Tremblay offered a number of observations about how things seem to come together. Building on McCarthy’s idea of speaking the language of communities, Tremblay suggested we need to similarly understand the differences in language between policy makers, care providers, and researchers. Integration also requires clear delineation of roles to facilitate mobilization and action. Tremblay argued we should not presume that actors at higher system levels are the only ones capable of leading integration. As McCarthy’s example illustrated, actors at local levels have the power to initiate and lead integration across many system levels. For Tremblay, integration is a living laboratory to create new status and roles best suited to meeting the needs of populations. It is a space for innovation and relates to collaboration, coordination, leadership, and community of action.

Tremblay compared the challenges for integration to a game of snakes and ladders – just as you think you are making progress you may find you are set back. We can learn ‘where are the snakes’ and ‘who has the ladders’ as we attempt to help make integration work. We have to keep in mind there is no magic bullet. Barriers for integration are related to the context and so attempting to manage barriers will only be met with other barriers. Key to success is contextualization - learning to adapt projects and maintain objectives in the face of barriers.